Etiquette, Ethics,

and
Ethical Concepts
in Healthcare
 Etiquette in Healthcare
• Proper etiquette endears a healthcare provider to the:
Client and the family
Colleagues and superiors
It contributes to health worker’s
Career advancement
Veneer
Confidence
• Medical etiquette can be defined as the rules that direct the
courteous conduct/manner of the healthcare provider towards
the patients and other healthcare professionals.
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• According to Clay (2018), ‘Good manners are a key component
of good team functioning and patient care in medical settings.’
• Etiquette when relating with patients
A health professional’s interaction with patients is critical to
relationship building and improved health outcome. A
professional with good manners must:
Introduce themselves to the patients.
Shake hands and take introductions from patient’s entourage.
Address patients as ‘sirs’ or ‘madams,’ ‘Mr. or Ms. until the
patient permits their first name use. Be formal.
Use appropriate language. Speak respectfully to the patient.
Maintain proper body language and professional and neat
appearance.
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Listen attentively and creatively to the patient.
Keep the patient’s information confidential.
Provide the patient with every information to make informed
decisions.
• General etiquette for healthcare professionals
Medical matters should not be discussed publicly.
 Maintain punctuality.
Retain professional tones in messages – emails and memos-.
Use correct spellings and right word choice.
Keep reports straightforward and simple.
Respect and acknowledge other health professionals –
professional courtesy.
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 Ethics
• Ethics prescribe the standard of operations in moral decision-
making.
• In healthcare, ethics is as old as medicine itself. For instance,
medical codes of practice such as the Hippocratic Oath have
provisions regarding ethical considerations in medical practice.
• Healthcare ethics refers to the moral principles that underlay
health professionals’ judgment daily to provide the best-
principled care for each patient or clinical situation.
• Ethical consideration in health care involves doing the right
thing while achieving the best patient outcome.
• Application of ethical theories, principles, rules, and guidelines
help in challenging clinical situations.
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 Ethical Theories
• Ethical principles, concepts, and rules arise from ethical
theories. These theories include:
Consequentialism – considers any action that results in good as
ethical. Actions resulting in bad effects become unethical.
Because of its simplistic analysis, it raises many questions.
Associated with John Stuart Mill.
 Utilitarianism relates with consequentialism. It argues that the
right action produces good or happiness for the greatest number
of people.
General good is preferred to the individual’s right.
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Deontology – fulfilling moral obligations to people makes one
act ethically.
Associated with Immanuel Kant.
Problem arises when fulfilling one’s duties results in bad
consequences.
Considering the consequences of one’s actions resolves this.
Also categorized as duty ethics, which focuses on the agent’s
motive or duty, not the consequences.
The moral standard followed by the agent is mostly religion-
based. E.g. Divine Command Theory (The Ten Commandments)
Example: providing the same care to a group without
considering the effects on resource availability and sustenance.
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Virtue Ethics – focuses on the qualities of the moral agent than
the acts.
Appropriating or cultivating character traits or mannerisms
considered appropriate makes one ethical.
Any one impeccably virtuous will always do the right thing.
Associated with Aristotle, MacIntyre, and Pellegrino.
Concepts of phronesis and eudaimonia associate with virtue
ethics.
Phronesis or practical wisdom adapts knowledge and decision-
making to specific situations in opposition to rigidly applying
rules.
It capitalizes on the good and lessens evil.
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Eudaimonia – translated as human happiness or flourishing.
Although virtue expects one to value the immediate interest of
another, seemingly contradictory in the pursuit of eudaimonia,
but doing so enhances it.
These ethical theories complement each other and
understanding them clarifies the underlying causes of
contentions in complex situations.
Their differences highlight the difficulties associated with
making ethically-sound decisions in healthcare settings.

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 Ethical Principles
• The application of ethical principles of autonomy,
beneficence, non-maleficence, and justice alleviates the
complexity involved in making principled and morally sound
choices in medical practice.
Autonomy refers to the respect accorded to the patient and
their right to make decisions.
This principle assumes that an informed, competent adult
patient has the right to make choices for themselves.
 The exception to this principle includes when:
 The patient is unfit to make autonomous decision for self.
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Is considered mentally incapable of making right decisions for
themselves. E.g. children, mentally-ill and demented patients.
• For a patient to make an autonomous decision, the clinician
should:
Explain fully the patient’s medical condition, their options for
treatment, and their advantages and disadvantages.
Identify the ability of the patient to retain the information.
Evaluate their options and arrive at a decision – patients’
autonomy is not absolute.
• Informed consent must be obtained from the mentally stable,
adult patient.
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 Beneficence

• Implies the health professional must do the ‘best good’ for their
patients in every situation. To apply this principle, the health
worker must consider:
The best option to resolve the patient’s medical problem.
The compatibility of the treatment options with the patient’s
circumstances and expectations.
• Beneficence considers medical options good for and acceptable
to the patient.
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 Non-maleficence: ‘do no harm’
• Underpins almost every aspect of the medical practice as a
treatment intended to do good can unintentionally cause harm.
• It helps clinicians make difficult medical decisions.
• When considered alongside beneficence and autonomy, and
doing nothing will cause harm, the clinician needs to
Explain the possible positive and negative effects of a proposed
treatment.
• To prevent harm to patients, clinicians must:
 Consider the associated risks with intervention or non-
intervention.
Decide whether they possess the required skills and knowledge
to perform the needed action.
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Treat the patient with dignity and respect.
Resource availability and staff can also do harm to patients.

• Non-Maleficence Vs. Beneficence

• Non-Maleficence does not consider treatments that cause more
harm than good.
• Beneficence considers every valid treatment option and ranks
them in order of preference.
• Beneficence responds usually to a specific situation, such as
determining the best treatment for a patient.
• Non-Maleficence is a constant in practice. For instance, a
doctor has a duty to provide medical attention to a patient
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 Justice
• Implies that every medical intervention must be:
Legal and
Respect the human rights of individuals.
• Based on this principle, treatments must be allocated fairly and
justly based on legislation even in dire distance between
demand and supply.
• Justice indicates that no one should be unfairly disadvantaged
in access to healthcare.
• The clinician could consider the following questions while
applying the justice principle:
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Is the intervention/treatment option legal?
Does the planned intervention unfairly contradict someone’s
human rights?
Is one group prioritized over another?
Will the prioritization of the said group be justified in terms of
overall net benefit to society or agreed moral conventions?
• Answers to these questions will help the clinician to make
justified choices.

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 Ethical Dilemmas (Ethical paradoxes or Moral dilemmas)
• The ethical principles, as highlighted earlier, often conflict
among each others.
• Such non-alignment or conflict results in ethical dilemmas.
• An example is a case where a patient disagrees with the benefits
of surgery as the best option recommended by a clinician and
prefers taking medications or herbal remedies. Autonomy will
require the clinician to heed the patient’s decisions; beneficence
will support the clinician’s endeavor to provide the most
beneficial treatment.
• Ethical dilemmas, therefore, refer to situations of conflicting
moral requirements without a straightforward resolution.
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• The clinician must identify the source of the antagonism to the
best treatment option and address it.
• Dilemmas could arise in surrogacy-decision making, where the
surrogate’s views contradicts the clinician’s.
• Ethical dilemmas illustrate a conflict of values.
Values refer to the a desired state that man attempts to promote
or enhance.
The complexities associated with healthcare make values
difficult to attain.
Ethics, therefore, attempts to protect the values and provides
compromises to reconcile the contradictions and preserve the
values.
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 Ethical Rules
• The relationship between a healthcare professional and each
patient forms the professional and ethical aspect of health
management.
• This relationship revolves round giving and using information –
sharing information between the patients who provide
information about their conditions and the care professionals
who use the provided information to provide management
plans.
• The ethical rules of consents, confidentiality and truth telling
relate to information use by health professionals and their
clients, and determine the ethical outcome of doctor-patient
relationships. They help resolve ethical dilemmas.
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 Consent
• Beauchamp and Faden (2004, 1279) define consent as the
‘autonomous authorization of a medical intervention … by
individual patients.’
• This implies that a patient has the right of choice to make
decisions about their medical care based on the information
provided by the healthcare professional throughout the process
of healthcare management.
• Consent is not relegated to acceptance of proffered management
plan but also to alternative treatments and to refusal of
treatments.
• Consent may be explicit or implicit.
 Explicit conflict can be given orally or in writing.
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The patient’s behavior indicates implicit consent.
Explicit consent is more preferable for most procedures.
• Consent is based on the principle of autonomy and respect for
persons.
• Respect for persons requires that health workers provide
opportunities that allow patients’ control over their lives and
defer from providing unwelcome interventions.
• Consent comprises of three components: disclosure,
• capacity/competence and voluntariness.

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 Components of Consent
• Disclosure: the process during which the health provider
provides the patient with information about:
The patient’s condition
 A proposed medical intervention – investigation or treatment -
and allowed the rights to make own decisions.
• Disclosure includes:
information about inherent risks, alternatives and consequences
of the proposed treatments or tests.
• Benefits of disclosure include:
Defense on the part of the physician in a law proceeding.
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Exchange of information
Establishment of trust
Cooperation of patient in proposed treatment options.
Patient’s empowerment.
• Disclosure is based on the ethical principles of autonomy and
beneficence.

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 Capacity/Competence
• Refers to the patients’ ability to understand the information
provided by clinicians and the consequences of their decisions.
• Described as the ‘gateway’ to the exercise of autonomy (self
rule) (Gunn, 1994).
• Cases arise where a patient refuses treatment considered
important by the doctor – a tension between respect for
autonomy and beneficence. Autonomy usually takes precedence
in such cases.
• Though every clinician should be trained to assess capacity,
there are situations that psychologists or psychiatrists, those
with specialist skills, are required to conduct the assessment.
• Documentation of the capacity assessment is essential for
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 Voluntariness
• Refers to patients’ right to make decisions about their health and
their personal information without undue influence.
• Factors affecting voluntariness
▪ Internal factors arising from the patient’s health conditions.
▪ External factors – involve the ability of others to exert control
over a patient by:
 Force - using physical restraints or sedation to enable
treatment-.
Coercion - the use of explicit or implicit threats to
ensure treatment-.
Manipulation - the deliberate omission or distortion of
information to compel a certain decision or accept a treatment-.
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• Rather than using these external factors, the clinician tries to
persuade the patient (appeal to the patient’s reason). The patient
is still free to choose.
• Tension exists between autonomy and paternalism (a clinician’s
need to act in the patient’s best interest based on training and
expertise), hence –
Clinicians should be mindful of the thin line between
persuasion and coercion – the duty to provide adequate
information to support a patient’s free choice in contrast with
allowing a patient’s actions/decisions to be considerably
controlled by others.
• Voluntariness is a legal requirement of valid consent.
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 Obstacles to Informed Consent
• It is rare to achieve fully informed consent in practice due to:
▪ Linguistic and cultural differences
▪ Diagnostic uncertainties
▪ Complexity of medical information
▪ Overworked medical workers
▪ Psychological barriers to rational decision making
• However, obtaining informed consent is a priority in the
healthcare relationship.
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• Exceptions to informed consent
▪ Voluntary giving over of decision-making capacity to the doctor
or a third party.
▪ When disclosure of information would cause harm to the
patient –therapeutic privilege-.
Truth-telling:
• The practice and attitude of being open and straightforward
with patients about health conditions and treatments.
• Works on the premise that truth is better than deception.

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• Hindrances to Truth Telling
▪ The concept of ‘protective deception’ where the doctor feels the
patient may not handle the whole truth and decides to select what
to tell.
▪ Some cultures and families consider it cruel due to the
‘supposed’ effects it will have on patients.
▪ Quite difficult in practice due to uncertainty in medical
diagnosis and the patient’s response. (Verify the patient’s
readiness/willingness).
▪ Ignorance is not an option that many patients desire.

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 Confidentiality
• Confidentiality operates on the expectation that the information
provided during clinical relationships are not to be disclosed by
a health professional to a third party, without permission -
Hippocratic Oath and ethical codes of practice -.
• Confidentiality is premised on trust and openness.
• Breach of Confidentiality
It is argued that confidentiality is not absolute and may be
legally permissible to be breached:
If there is a risk of serious harm to patient or others.
Sharing information among the healthcare team for a better
management of the case.
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 Advocacy
• The patients contend with challenging situations in healthcare
settings and management. These challenges range from
confusing medical bills and insurance coverage, navigating
one’s healthcare and the system, inequities and access to quality
care to client’s support system.
• Advocacy supports the patient’s cause and seeks support from
others on behalf of the patient, dealing with public policy,
resource allocation, and care services,
• It includes speaking up and drawing attention to client’s issue
and effecting changes or propelling actions in:
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The patient’s life or environment (community)
Program or service (hospital or a program like dialysis center)
Policy
Hence, advocacy is not limited to an individual patient, but
includes-
Community outreach programs
Performance improvement activities in organizations
National lobbying activities for policy changes.
In healthcare delivery, advocacy centers on the patient’s:
Health condition
Health care resources
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Quality of life
Client and society’s needs
The advocate is ethically obligated to –
Do what serves the best interest of the client and family,
including:
Protecting and promoting client's autonomy and
empowerment.
Promoting shared decision-making and information
availability
Promoting client’s safety, rights, and quality of received care.
Eliminating deficiencies from the delivery of health care
services (securing services/resources).
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Providing avenues for just and fair distribution of resources.
Generally, serving as the voice of the client, family and society to
ensure health promotion and access to quality care.
Hence, the health advocate, whether a case manager, patient
representative, health adviser, an educator, independent practice
or non-governmental agency, etc. -
Supports the client from identifying the problem until a
supportive care environment exists.
• Levels of advocacy
Client (individual) advocacy
Organizational (service) advocacy – health care organizations
Community (population) advocacy.
Global (national or state) advocacy – politically-inclined.
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Accountability
• Globally, healthcare currently faces problems with managing
the increasing health demands and the financial implications of
quality care, highlighting the need for accountability.
• Accountability, therefore, raises questions concerning:
Means of improving care quality and safety for individuals and
the population
Health cost
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 References
Tahan, H.M. 2016. Essentials of advocacy in case management:
Part 1: ethical underpinnings of advocacy—theories, principles,
and concepts. Professional Case Management, 21(4), pp. 163-
179. https://doi,org/10.1097/NCM.0000000000000162.
Kitchens Jr., L,W. 1995.Viewpoint: Medical etiquette. Baylor
University Medical Center Proceedings, 8(3), 7-10.
https://doi.org/10.1080/08998280.1995.11929924.
Varkey, B. 2021. Principles of clinical ethics and their
application to practice. Med Princ Pract., 30(1),17-28.
https://doi.org/10.1159/000509119.

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