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Week 9 - The Ashley Treatment; which ethical theories apply?

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Week 9 - The Ashley Treatment; which ethical theories apply?

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Week 9 - The Ashley Treatment; which ethical laws apply?

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Week 9 - The Ashley Treatment; which ethical laws apply?

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Week 9 - The Ashley Treatment; which ethical principles apply?

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Week 9 - The Ashley Treatment; which ethical principles apply?

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Week 9 - The Ashley Treatment; which ethical concepts apply?

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Week 9 - The Ashley Treatment; which ethical concepts apply?

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This guest post has been graciously provided by Robert Newsome, III, JD. His articles on this subject and others can be found in the journals Nursing Ethics, Nursing Philosophy, and the Journal of Nursing Law.
Ashley X was born in 1997 in Seattle, Washington. After the first month of life, she "began to display symptoms of hypotonia, feeding difficulties, choreoathetoid movements, and developmental delay". Consultation with all relevant specialties could identify no specific cause for her condition, resulting in a diagnosis of "static encephalopathy with marked global developmental deficits." In the ensuing years, her condition has, in many of these respects, remained unchanged. She is, and in the opinion of her physicians always will be, unable to sit up, roll over, grasp objects, or speak. She must be fed through a gastrostomy tube. Ashley is now 15 years old, and is experiencing life with the cognitive resources typically available to a 3-6 month old child (Diekema, 2010).

Shortly after her 6 th birthday, Ashley began precocious puberty. Over a period of the ensuing 3 years, Ashley received high doses of estrogen, a growth attenuation treatment that has resulted in her remaining relatively small in stature, likely to never be larger that 4 feet 6 inches (1.37 m) tall, and weighing about 65 or 70 pounds (29-32 kg). Ashley also underwent a hysterectomy and breast bud removal (Diekema, 2010). This combination of medical interventions are now known, for good or ill, as "the Ashley Treatment".

The Ashley Treatment has been, and remains, controversial. It has been over 5 years since the Ashley Treatment was first described in a medical journal, but it remains a lively topic, for several reasons. One reason the controversy has not gone away is that the Treatment has not gone away; it is being administered in additional cases (at least 12 worldwide), and perhaps thousands of families around the world are exploring it. In the United States, The National Disability Rights Network has recently published a report which calls upon Congress, and State legislatures, to pass legislation which prohibits the Ashley Treatment.

Another reason for continued interest in the Ashley Treatment is the sheer number of issues it raises. Some of these issues are primarily legal in nature. Does the hysterectomy component of the Ashley Treatment constitute the involuntary sterilization of an incompetent, which if done without prior judicial approval is unlawful and a violation of the incompetent individual's constitutional rights? Should all highly invasive procedures require judicial approval before being performed on incompetent individuals, or should surrogate decisionmakers continue to enjoy broad discretion in such matters?

Other issues raised by the Ashley Treatment are more broadly philosophical. Even if, as I have argued elsewhere, surrogates may lawfully elect each component procedure of the Ashley Treatment without first obtaining judicial approval, and parents should continue to enjoy broad discretion in deciding what course of treatment is in their child's best interest, could choosing the Ashley Treatment EVER be in ANY child's best interest? It would seem that at least some commentators believe that the answer to that question is a resounding "No". What I wish to suggest, in what follows, is that, whether or not the "Ashley Treatment" was, in fact, in Ashley's best interests, there may be cases where it could be in some child's best interests, and should therefore not be strictly forbidden.

Opposition to the Ashley Treatment comes from many different perspectives. Many of these objections have been addressed elsewhere ( see Diekema 2010, Edwards 2011), and I have discussed some of them elsewhere ( see Newsom 2007, Newsom 2009). However, there have been some objections raised to the Ashley treatment by very able feminist philosohers that I feel have, to date, been given insufficient attention.

Since my career as a nurse has been in skilled nursing/long term care, the broad topic of disability has been of particular personal concern to me. In my working nursing life I am a "Charge Nurse", not a "Nurse Manager"; I take vital signs, wipe bottoms, bathe bodies, transfer patients from bed to chair, feed people who cannot feed themselves, give them their medicine, change their colostomy bags and the dressings on their wounds, etc. I am one of those people who, to quote Martha Nussbaum, does "all the work that extreme dependency requires" (one could say, I suppose, that I am part of Annette Baier's "moral proletariat"). Here, the contibution of feminist philosophers has been uniquely valuable. And no one book by a philosopher has meant more to me, on a personal and professional level, than "Love's Labor", by Eva Fedder Kittay. If ever there was a book by a philosopher that was "for nurses", it is "Love's Labor". On the one occasion I met Dr. Kittay in person, and in brief e-mail correspondence with her, I have always felt it best to hold back my enthusiasm for this book, and my personal admiration for her as a philosopher and a person, lest she think she was dealing with a madman and an internet stalker.

Dr. Kittay has contributed to the conversation on the Ashley Treatment, but seems to have come to a different conclusion about it than I have. I find this troubling and not a little intimidating. In Dr. Kittay's case, I am truly reluctant to disagree with her about any matter of substance. I hope that, by examining our differences on the Ashley Treatment, I can add something new and constructive. So with GREAT trepidation, "here goes."

There are many things that Dr. Kittay, and other philosophers like Dr. Adrianne Asch, say about disability in general, and Ashley's case in particular, with which I completely agree. First, Dr. Kittay writes movingly of "the extraordinary possibilities inherent in relationships of care with one who reciprocates but not in the same coin, one who cannot be independent, but repays with her joy and her love" (Kittay, 2011). That seems exactly right, and I shall have more to say along these lines at the end of this post.

Second, and specifically in regard to Ashley, Dr. Kittay writes that "The philosophers, however, have made the capacity for rational thought a criterion for dignity...Those creatures who don't reach the mark are 'without dignity.' With one stroke, the Ashleys of the world...are placed below the line...we have learned the lessons that Ashley and our daughter Sesha have to teach those who create false idols of intellectual capacity: Life is precious; all individuals have intrinsic worth, the source of their dignity; and joy..." (Kittay, 2007). I think this is exactly right as well. Ashley's cognitive and other deficits do not diminish her dignity, or make her life less precious. My only reservation here is with the phrase "The philosophers", as I think a number of philosophers in the western cannon have provided us with the resources to see things much as Dr. Kittay sees them (at least if read charitably).

Dr. Asch and Dr. Anna Stubblefield have written that "Ashley is the same as most people. She is the same in deserving to be accepted by and respected by and loved by her family for who she is and what she will become, with no modification required" (Asch). I think that is exactly (or at least mostly) right as well.

Each of these philosophers is committed to the claim every child should be loved and embraced with the characteristics and capacities that they have, whatever those might be, and whether or not those capacities include "the capacity for rational thought". This claim is true, and I am truly afraid (very afraid) of anyone who does NOT accept it.

With so much agreement here, how can any disagreement arise? First, Dr. Asch and Dr. Stublefield point out that since very large people who have lost, or who have never had, the ability to ambulate, use their arms and hands, swallow, speak, etc, can nevertheless participate in family and community life with enough help, and enough "gear" (like the "hoyer lift"), the Ashley Treatment is not necessary (Asch). I think this claim is true, but does not establish that the Ashley Treatment might not sometimes beneficent, because we can, and should, perform many beneficent acts that are not "necessary".

Second, work by both Dr. Kittay and Drs. Asch and Stubblefield suggests that, since it is possible to be wrong about any individual's "cognitive abilities", and future prospects for growth and development, the Ashley Treatment was approved based on assumptions about Ashley's future that no one is entitled to make (Asch, Kittay 2007). I will argue that this second claim needs to be very carefully evaluated and that, after doing so, it should be concluded that an assessment of our knowledge (and its limits) about Ashley's capacities, prospects and "inner life" do not support for the conclusion that the Ashley Treatment is always, and everywhere, wrong.

Third, Drs. Asch and Stubblefield claim that medically altering any characteristic or capacity a child might have violates our duty to "love and embrace" that child. I would argue that this claim is false, and think it is significant that Dr. Kittay stops short of making such a claim (Asch, Kittay 2007).

Considering these claims in reverse order, I conclude that we might fully love and embrace a child with whatever characteristics and capacities they have (or lack), and still conclude that their life might be, all things considered, better if one or more of those characteristics were altered. I don't, for example, think that parents who elect otoplasty for their child ( a procedure that is NOT medically necesary) are failing to fully love and embrace that child, "no modification required". Rather, they have simply decided that their child's life will be better if they are not nicknamed "Dumbo" by their peers during their formative years.

Parents have many duties that they owe to their children, of which the duty to "love and embrace, no modification required" is only one. Another duty that parents have is to make choices on behalf of their children which will, if all goes well, facilitate the best possible future for them. What is more, there are some reasonably clear cases where, in order to do so, medical intervention to modify growth will be something a parent should do, and we need look no further to illustrate this point than to examine the condition that brought Ashley to the endocrinologist, Dr. Gunther, in the first instance.

While the background information about Ashley's lifelong care is sometimes frustratingly incomplete, it seems that Ashley's parents obtained an endocrinology consultation due to the onset of precocious puberty, as diagnosed by her pediatrician. Girls experiencing precocious puberty will have a "growth spurt" and, for a time, be taller than their peer group. However, since puberty will end for them at an earlier age than would otherwise be the case, they will be shorter, as adults, than they would have been if puberty had been delayed. They will, in other words, never reach their "full" potential height. What to do? Modify their growth by administering drugs called LHRH analogs - synthetic hormones that block the body's production of the sex hormones that are causing the early puberty. The precocious puberty stops (indeed, it sometimes reverses, so to speak - breasts become smaller, pubic hair disappears, etc.), and then puberty begins again at a more "appropriate" age.

Should a parent authorize medical intervention to "treat" their daughter's precocious puberty, which sometimes occurs for no identifiable reason? Yes. There are good reasons for parents to do so, even though they might "fully love and embrace" their precociously pubescent daughter. Some reasons are medical; for example, mounting evidence suggests precocious puberty significantly heightens the risk of breast cancer, and of mental health disorders. Other reasons are social; precocious puberty puts girls at a higher risk for teasing and bullying.

It thus seems that it is possible for a parent to fully love and embrace a child and nevertheless elect to medically "alter" that child, where a parent reasonably believes that in doing so they advance their child's interests.

The second claim, that the Ashley Treatment was approved based on assumptions about Ashley's future that no one is entitled to make, might seem plausible, since a) any medical diagnosis and/or prognosis might be erroneous, and b) we might think we never really "know" what the inner life of someone else is like. I think a) is true, but am unsure if knowing that it is true takes us very far when we make decisions about our health, or the health of our dependents. This is especially true in the case of prognosis, but can certainly be true with diagnosis as well. Consider the following simple example.

Wilm's tumor is a rare malignant tumor of the kidney which develops in childhood. There are clusters of signs and symptoms which lead physicans to suspect the presence of "Wilms tumor". However, it also possible that the diagnosis is mistaken; that "mass" showing up on the X-ray MIGHT be a begnin lump of tissue known as "metanephric adenofibroma". If it is, surgery is not a "medical necessity". Still, metanephric adenofibroma is an even more rare condition that Wilm's tumor, and the consequences of NOT surgically removing a Wilm's tumor are certain death. In other words, a diagnosis might be wrong, but it would nevertheless be a mistake NOT to accept it as true when deliberating upon what to do. The parent who decides to just HOPE that this is simply a case of metanephric adenofibroma would seem, at least to me, to be more than a little daft.

In the case of prognosis, we are similarly unlikely to obtain the degree of certainty that the village verificationist or annoying sophomore skeptic would say we need in order to justify a claim of "knowledge". Continuing on with the Wilm's tumor example, even if the tumor is excised while it is "stage 1", the patient is "cured" in over 90%, but less than 100%, of such cases. So, we might not want to say that we "know" the child in question is cured (at least when certain epistemologists and sophomores are in earshot). We might want to say, instead, that we hope this child is cured, and that the hope is not a vain and fanciful one, but rather is based on evidence, and pretty good evidence at that. We would not think, given our collective experience, that a parent who hopes their child is cured is, under these circumstances, simply blinded by parental love and engaged in wishful thinking.

With Ashley, of course, matters are not as simple. A diagnosis of "static encephalopathy with marked global developmental deficits of unknown etiology" is an admission that there is a lot here that medicine does not know. No one has any published explanation that I have been able to find concerning what sort of massive insult Ashley's brain received, or when, exactly, it occurred. Some commentators have been, and are, suspicious of this diagnosis, and the prognosis accompanying it. Disability activist Anne McDonald remarked that in accepting the conclusion that Ashley will not significantly develop cognitively, ethicist Peter Singer ''has accepted the doctors' eyeball assessment of Ashley without asking the obvious questions. What was their assessment based on? Has Ashley ever been offered a way of showing that she knows more than a 3-month-old baby?" (McDonald 2007).

I have two thoughts here. First, whence commeth the knowledge, on McDonald's part, that the physicians treating Ashley performed only an "eyeball assessment"? Was she there? Had she examined all of Ashley's medical records? Yes, there are reasons to think that historically medical science has, as Drs. Asch and Stubblefield have noted, often underestimated "the cognitive abilities of people who appear to be profoundly intellectually impaired" (Asch). This does not tell us that Ashley's cognitive abilities have been underestimated. Even more to the point, it does not establish that physicians and cognitive scientists are never entitled to make a prognosis like the one Ashley's physicians made, or that parents would always be wrong to accept such a prognosis and act upon it.

This leads to consideration of b), above; how can we "know" what it is "like" to be Ashley, with these deficits, if we can reasonably conclude she has them, and always will? Here, I think, those of us who have argued that the Ashley Treatment might sometimes be beneficent have not been careful enough with our choice of words. I know that I have been guilty of saying, in the past, that Ashley probably has the emotional and cognitive life of a typical 3-6 month old child. What I SHOULD have said is that Ashley is a 15 year old girl who lives her life utilizing the cognitive capacities, or tools, available to a 3-6 month old child. There is a difference between those two statements.

What we find ourselves confronted with here with b) is a version of an old philosophical puzzle, the "problem of other minds", and a favorite of the aforementioned "sophomore skeptic", that wretched student sitting in the front row of my introduction to philosophy class who asks "how do you know that grass looks the same to you as it looks to me?" I have, so far, always been able to resist the temptation to strangle such an individual by reflecting on the fact that, in one way or another, the pernicious meme that my "mind", and yours, are "private" and accessible only to you and me, has found its way, like some lethal prion, in to the brains of people of true genius (and far better philosophers than me) on many occasions.

This isn't the forum in which to publish the dissertation I never wrote, so I will content myself with the bald assertion that "how grass looks to me", and "what it is like to be Ashley" are not things that are "known", if by "know" one means something like "able to select the correct answer on the multiple choice exam". There are, however, MANY things I can justifiably BELIEVE and FEEL about life as Ashley lives and experiences it, and many other people for that matter, as well as non-human creatures great and small.

I have a well justified belief that Ashley is aware of her environment and responds to it. Moreover, I believe that her response to her environment today utilizes resources accumulated by her awareness of the environment in the past. For example, we are told that Ashley goes to school daily, and responds to arriving there with smiles, happy sounds and kicks. I have no reason to think Ashley forms the "rational" thought "I'm in school today, just like I was yesterday. This is great!", but there is good reason to believe that her acquaintance with school, over time, causes her to, as William James once put it, "find it warm" . Using the term "knowledge" in the context of this "accumulation from acquaintance" would send any number of philosophers in to fits of rage, so I won't do that. But I do think we must conclude that something like it is a part of what it is to be Ashley. Ashley has feelings which are informed by her experience over time.

It may be that what Leplace said about the astrophysics of his day should be said about the cognitive science of today - "What we know is not much. What we do not know is immense." However, "not much" is not the same as "nothing". And, among those things that we do know, is that we should not dismiss the wisdom and value of feelings. For those who are inclined to do so, I recommend a dose of Martha Nussbaum's "Upheaval of Thought", wherein Dr. Nussbaum makes an impressive case for understanding feelings (yours, mine and Ashley's) as judgments of the importance of what those feelings are about to our well being.

Why attribute this sort of very rich inner life to Ashley? One good reason to do so is that we need that hypothesis to understand what Ashley does. And, I might add, this illustrates why it is very important NOT to think of Ashley as "3-6 months old". The "tools" she deploys to be aware of her environment may be the tools of a 3-6 month old child deploys, but those tools have been deployed for the last 15 years, not 3-6 months. What is more, there is every reason to believe that you and I use those tools also, and that how they shape and inform who we are is every bit as important as our "rational" life. Since we do deploy these same tools ourselves, we can therefore know at least something about what it is like to be Ashley. In fact, if we accept the descriptions of Ashley and her life today provided by her family (and I know of no reason not to), we know many things about what it is like to be Ashley, and, of course, her parents, siblings and teachers know many more.

We know, because of our capacity for what David Hume and Adam Smith called 'sympathy" (I think they had in mind what we call "empathy" today), what music pleases Ashley, what places Ashley likes to go, that she enjoys being picked up, cuddled and carried by her parents and grandparents, etc. In fact, this is a phenomenon that I have observed so often over the last 15 years of my life as a nurse that I have only recently begun to understand how significant it truly is, a purloined philosophy lesson hidden from me in plain sight.

In more cases than I can count, I have observed adults who have lost the capacity for rational thought, through Alzheimer's Disease, nevertheless continue, for a time, to have a very rich "inner life", filled with love and caring. I have seen caregivers develop a deep and rich understanding of what that person's inner life is "like", and respond to that person in truly remarkable ways as a result of that understanding. I have done so myself many, many times, without engaging in "rational" thought while doing so, or understanding the significance of what I had done. David Hume was right: "The minds of men are mirrors to one another."

This leads, at long last, to the observation, by Drs. Asch and Stubblefield, that there is no NECESSITY to attenuate growth in order to facilitate good care (Asch). We do in fact lift, transfer and reposition even bariatric patients on a daily basis. For over a year one of my patients was a lady who weighed over 500 lbs, and she was up, dressed, eating lunch in the dining room and playing bingo every day, thanks to specialized equipment. She was also completely free of pressure ulcers thanks to a special bed. We hugged each other each time I came on duty. Ashley could, obviously, go to school, participate in family and community life, never get a pressure ulcer, receive hugs, and so forth, without growth attenuation.

But, matters do not end there. Caring feels most genuine and rewarding when it is unmediated by the mechanical and the non-human. There is more to caring than just transferring, repositioning, providing novel experiences, cleaning and washing. Consider this recollection of Ann McDonald's, describing life in the institution in which she was confined: "Nurses were discouraged from cuddling children. A crying child needed to be punished for its own good, so it would learn to accept the absence of affection and be happy. Punishment consisted of locking the crying child in a small dark store room" (McDonald, "14 years").

One obvious thing to conclude from Ann's recollection is that some people who are nurses should be doing something else for a living, as they apparently lack a capacity (empathy) we are presently unable to supply upon demand. But the other thing we should conclude is that human touch is a critical component of human caring. It is comforting in ways that the mechanical is not. Ann's institution would have not been less of an absolute, shameful, hellhole if it had contained "hugging machines" to stick children in, instead of dark closets.

It is for this reason that I will confess that I don't like hoyer lifts. I do not like putting patients in a sling and lifting them, like a horse you are transferring from a ship to a barge, with the aide of a machine. What is more, most patients don't really like them either, and will tell you so if you ask. Those who are cognitively intact will tell you so in words; those who are not will let you know in other ways.

This not to say that hoyer lifts, and other assistive technologies, are not "good" things. One thing that is good about them is that, when the care of the fully grown adult is involved, they protect the caregiver. The fact that I do not like hoyer lifts, and did not use them as often as I should have (for my own good) early in my nursing career undoubtedly helps to account for the two ruptured discs in my back that cause me constant discomfort, have necessitated two emergency room visits, and may, in the not too distant future, place me in the ranks of the "disabled" as well. And, of course, many patients understand the wisdom of mechanical lifts; they are nice people who do not want their caregivers to sustain injuries. Sometimes a patient will INSIST that I, the nurse, use the lift because THEY have come to deeply care about me (one of the many rewards that nursing offers). Nevertheless, neither of us LIKE the damn things.

One big idea that seems to be distinctly feminist is Eva Kittay's observation that western philosophy has made a "false idol" out of the intellectual capacity for rational thought, singling it out as the sine qua non for dignity, value and worth (Kittay 2007). Even if, as I maintain, there are historical figures in philosophy who were not utterly bewitched by "reason" (Spinoza, Shaftesbury, Hume and Smith come to mind), this feminist critique of the western philosophical cannon gets the "theme" right, starting with Plato and Aristotle, and with no clear end in sight.

If I am reading them accurately, Drs. Asch, Stubblefield and Kittay suspect that the defenders of the Ashley Treatment think growth attenuation is appropriate for individuals who do not have, and never will have, the capacity for "rational thought", and are, therefore, just repeating the same damn mistake old dead white men philosophers have made for the last 2,500 years (with, perhaps, a few honorable exceptions). Defenders of the Ashley Treatment, they suspect, are viewing those lacking "reason" as "less than" the rest of us, and so we can do things with them, and to them, that we cannot do with, and to, those possessed of reason (eat them, ride them, make them pull plows, lock them in cages, attenuate their growth, etc.). Perhaps defenders of the Ashley Treatment are, one might say, unjustifiably "privileging" reason over other ways of "being in the world". I, as one of those "defenders," plead "not guilty".

For surely, when we stop worshiping at the altar of the false idol of reason, we should become better able to value the role that the other, "feeling" way of "being in the world" plays in our life, and the lives of others. We should stop "thinking" that a crying child needs to be locked in a dark closet, and "feel" compelled to pick the child up and cuddle it instead. We should better comprehend what Ashley tells us, because Ashley does tell us things. Among many other things, Ashley tells us she loves tenors, school, and and being picked up, held and carried by those whose touch she finds comforting and warm. We might "feel" that, if the only way of "being in this world" for Ashley is the "feeling" way, then Ashley might be able to experience greater joy and love as a small woman than a large one when other factors, such as being unable to swallow, turn over, or grasp objects are also part of who she is. If so, helping Ashley be a small woman is not a failure of love and acceptance, but an act OF love and acceptance. In defending the availability of the Ashley Treatment, my intention is to privilege, not "reason", but "feeling", as a way of being in the world.

I want to think, even if Dr. Kittay cannot agree, that those who have elected the Ashley Treatment for Ashley have done so not because they worship a "false idol of reason", but because, instead, each time they pick her up in their arms and hold her, they experience, in a unique and special way, exactly what Dr. Kittay describes: "the extraordinary possibilities inherent in relationships of care with one ... who cannot be independent, but repays with her joy and her love", and that Ashley does also. If so, they worship (if that is the word) at a different altar, one not consecrated to some jealous God called "reason"; and I see no compelling "reason" to forbid it.
Robert Newsome is a nurse, a lawyer, and a philosophy professor. As mentioned, his writing, on this topic and others, appears in the journals Nursing Ethics, Nursing Philosophy, and the Journal of Nursing Law. References
Asch, A. and Stubblefield, A. Growth Attenuation: Good intentions, Bad Decision. American Journal of Bioethics 10(1): 46-48. 2010.

Diekema,D. and Frost, N. Ashley Revisited: A Response to the Critics. American Journal of Bioethics 10(1): 30-44, 2010

Edwards, S. The case of Ashley X. Clinical Ethics 6: 39-44. 2011.

Kittay, E. The Ethics of Care, Dependence, and Disability. Ratio Juris Vol. 24 No. 1: 49-58. March 2011.

Kittay, E. and Kittay, J. Whose Convenience? Whose Truth? A Comment on Peter Singer's "A Convenient Truth". Bioethics Form - Diverse Commentary on Issues in Bioethics. 02/28/2007. Online: http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=350

McDonald, A. 14 Years in St. Nicholas. No Date of Authorship. Available online:
http://www.annemcdonaldcentre.org.au/anne-14-years-st-nicholas
McDonald, A. The other story from a 'Pillow Angel'. 2007. Online: http://www.seattlepi.com/local/opinion/article/The-other-story-from-a-Pillow-Angel-1240555.php

Newsom, R. Seattle Syndrome. Nursing Philosophy 8: 291-294. 2007.

Available online: https://www.box.com/s/b9ddab138f6eaa4411b3

Newsom, R. In Her Best Interests. Journal of Nursing Law Vol 13 No.1: 25-32. 2009. Available online: https://www.box.com/shared/dtlotfzp68

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The Philosophy and Ethics of Growth Attenuation

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Ashley X Case on Fox News - Glenn McGee - Bioethics

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Week 8 - do not resuscitate; what is the ethical problem? Identify ethical conflicts. Consider the law. Identify a way forward.

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Week 8 - do not resuscitate; what is the ethical problem? Identify ethical conflicts. Consider the law. Identify a way forward.

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Week 8 - mental illness and ethical practice; what is the ethical problem? Identify ethical conflicts. Consider the law. Identify a way forward.

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Week 8 - mental illness and ethical practice; what is the ethical problem? Identify ethical conflicts. Consider the law. Identify a way forward.

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Week 8 - mental illness and ethical practice; what is the ethical problem? Get the facts. Consider the core ethical principles. Consider the different perspectives.

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Week 8 - mental illness and ethical practice; what is the ethical problem? Get the facts. Consider the core ethical principles. Consider the different perspectives.

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Week 8 - refusal of treatment her; what is the ethical problem? Identify ethical conflicts. Consider the law. Identify a way forward.

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Week 8 - refusal of treatment her; what is the ethical problem? Identify ethical conflicts. Consider the law. Identify a way forward.

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The case of Cassandra C., a 17-year-old in Connecticut who refused to continue receiving chemotherapy to treat her Hodgkin's lymphoma, poses a genuine ethical dilemma. The dilemma stems from a conflict between two leading ethical principles. One principle, respect for autonomy, calls for respecting individuals' right to self-determination. In the medical context, that means allowing people to refuse medical treatment, even lifesaving therapy. The other ethical principle, bene ficence, directs physicians and hospitals to maximize benefits and minimize harms in caring for patients.

The problem in Cassandra's case is that she is still legally a minor, which means that a parent or guardian has the legal authority to make healthcare decisions on her behalf. But unlike problematic cases in which parents and their offspring disagree about medical treatment, Cassandra's mother upheld her daughter's refusal of treatment.

Court Decisions to Date
Courts have the authority to overrule parents when their medical decisions threaten the life or health of their offspring. In such cases, temporary custody is removed from the parents and a specific guardian (termed a "guardian ad litem") is appointed to make medical decisions for the minor.

On January 8, 2015, the Connecticut Supreme Court upheld a lower court decision and ruled that Cassandra must continue to undergo chemotherapy against her will. Separate lawyers for the mother and daughter sought to have the teen considered a "mature minor," which would grant her the right to refuse lifesaving treatment, but the court declined to rule on that aspect, siding with the medical judgment that there is an 85 percent chance of surviving Hodgkin's lymphoma by treating with chemotherapy.

Years ago at Albert Einstein College of Medicine we had a neonatal ethics committee that advised physicians in ethically troubling cases. A leading principle used in the committee's deliberations was the following: "Parents are presumed to be the decision-makers for their children unless their decision is clearly against the best interest of the child." The committee spent considerable effort seeking to determine when a parental decision was clearly against the infant's best interest. Newborns and young children cannot make such judgments for themselves, but what about a teen who will reach the age of majority within a year?

Exploring the Ethics
The legal barrier to respecting Cassandra's autonomy remains, but the ethics of the case are murky. If this were a one-shot treatment-perhaps painful or uncomfortable but over quickly-it would be easy to conclude that forced medical treatment would do more good than harm. But that is not clearly the case when the patient has to endure for as long as six months the discomforts of chemotherapy.

In December Cassandra first underwent surgery to install in her chest a port through which the drugs would be administered. State officials took custody of Cassandra and confined her in the hospital, Connecticut Children's Medical Center, where she has received the forced treatments. Her cell phone was taken away (for a teen, this may be worse than the nausea and vomiting) and the phone in her hospital room was also removed. Her mother has been allowed to visit her in her hospital room, but only with a child welfare worker present. Mother and daughter are not allowed to have contact by phone.

In an op-ed piece published in the Hartford Courant, Cassandra said that the Connecticut Department of Children and Families had had her medically evaluated and placed in a foster home until the court date. Describing her ordeal once she was confined to the hospital for the forced treatment, she wrote: "I was strapped to a bed by my wrists and ankles and sedated."

Uncertain Resolution
There is no way of knowing what Cassandra will say if she is eventually cured of her cancer. She might be grateful that her life was saved, and thank the doctors and the hospital for involving the courts to force the chemotherapy. Or she might remain resentful, claiming that her autonomous right to refuse medical treatment was violated. But whatever she might say, her judgment in the matter does not resolve the ethical dilemma. She is still legally a minor, but that does not ethically justify the actions of the doctor, the hospital, the child welfare agency and the Connecticut courts. Although reasonable people may disagree on whether a 17-year-old should be forced to undergo medical treatment against her will, we should not condone the brutality involved in placing this young patient in a foster home, sedating her and strapping her down in a hospital bed. The philosopher Immanuel Kant wrote that "whoever wills the end, wills the means." However, even those who initially support a plan to force treatment on a young patient are morally bound to question the means required to do so.

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The Ethical Dilemma of Forced Chemotherapy on a Teen | The Doctor's Tablet

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The case of Cassandra C., a 17-year-old in Connecticut who refused to continue chemotherapy to treat her Hodgkin's lymphoma, poses a genuine ethical dilemma.

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Week 8 - refusal of treatment her; what is the ethical problem? Get the facts. Consider the core ethical principles. Consider the different perspectives.

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Week 8 - refusal of treatment her; what is the ethical problem? Get the facts. Consider the core ethical principles. Consider the different perspectives.

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The case of Cassandra C., a 17-year-old in Connecticut who refused to continue receiving chemotherapy to treat her Hodgkin's lymphoma, poses a genuine ethical dilemma. The dilemma stems from a conflict between two leading ethical principles. One principle, respect for autonomy, calls for respecting individuals' right to self-determination. In the medical context, that means allowing people to refuse medical treatment, even lifesaving therapy. The other ethical principle, bene ficence, directs physicians and hospitals to maximize benefits and minimize harms in caring for patients.

The problem in Cassandra's case is that she is still legally a minor, which means that a parent or guardian has the legal authority to make healthcare decisions on her behalf. But unlike problematic cases in which parents and their offspring disagree about medical treatment, Cassandra's mother upheld her daughter's refusal of treatment.

Court Decisions to Date
Courts have the authority to overrule parents when their medical decisions threaten the life or health of their offspring. In such cases, temporary custody is removed from the parents and a specific guardian (termed a "guardian ad litem") is appointed to make medical decisions for the minor.

On January 8, 2015, the Connecticut Supreme Court upheld a lower court decision and ruled that Cassandra must continue to undergo chemotherapy against her will. Separate lawyers for the mother and daughter sought to have the teen considered a "mature minor," which would grant her the right to refuse lifesaving treatment, but the court declined to rule on that aspect, siding with the medical judgment that there is an 85 percent chance of surviving Hodgkin's lymphoma by treating with chemotherapy.

Years ago at Albert Einstein College of Medicine we had a neonatal ethics committee that advised physicians in ethically troubling cases. A leading principle used in the committee's deliberations was the following: "Parents are presumed to be the decision-makers for their children unless their decision is clearly against the best interest of the child." The committee spent considerable effort seeking to determine when a parental decision was clearly against the infant's best interest. Newborns and young children cannot make such judgments for themselves, but what about a teen who will reach the age of majority within a year?

Exploring the Ethics
The legal barrier to respecting Cassandra's autonomy remains, but the ethics of the case are murky. If this were a one-shot treatment-perhaps painful or uncomfortable but over quickly-it would be easy to conclude that forced medical treatment would do more good than harm. But that is not clearly the case when the patient has to endure for as long as six months the discomforts of chemotherapy.

In December Cassandra first underwent surgery to install in her chest a port through which the drugs would be administered. State officials took custody of Cassandra and confined her in the hospital, Connecticut Children's Medical Center, where she has received the forced treatments. Her cell phone was taken away (for a teen, this may be worse than the nausea and vomiting) and the phone in her hospital room was also removed. Her mother has been allowed to visit her in her hospital room, but only with a child welfare worker present. Mother and daughter are not allowed to have contact by phone.

In an op-ed piece published in the Hartford Courant, Cassandra said that the Connecticut Department of Children and Families had had her medically evaluated and placed in a foster home until the court date. Describing her ordeal once she was confined to the hospital for the forced treatment, she wrote: "I was strapped to a bed by my wrists and ankles and sedated."

Uncertain Resolution
There is no way of knowing what Cassandra will say if she is eventually cured of her cancer. She might be grateful that her life was saved, and thank the doctors and the hospital for involving the courts to force the chemotherapy. Or she might remain resentful, claiming that her autonomous right to refuse medical treatment was violated. But whatever she might say, her judgment in the matter does not resolve the ethical dilemma. She is still legally a minor, but that does not ethically justify the actions of the doctor, the hospital, the child welfare agency and the Connecticut courts. Although reasonable people may disagree on whether a 17-year-old should be forced to undergo medical treatment against her will, we should not condone the brutality involved in placing this young patient in a foster home, sedating her and strapping her down in a hospital bed. The philosopher Immanuel Kant wrote that "whoever wills the end, wills the means." However, even those who initially support a plan to force treatment on a young patient are morally bound to question the means required to do so.

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The Ethical Dilemma of Forced Chemotherapy on a Teen | The Doctor's Tablet

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The case of Cassandra C., a 17-year-old in Connecticut who refused to continue chemotherapy to treat her Hodgkin's lymphoma, poses a genuine ethical dilemma.

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Week 8 - women sues for reviving her; what is the ethical problem? Identify ethical conflicts. Consider the law. Identify a way forward.

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Week 8 - women sues for reviving her; what is the ethical problem? Identify ethical conflicts. Consider the law. Identify a way forward.

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A lawsuit filed on behalf of a New Mexico author alleges that a Santa Fe hospital revived the woman in violation of her "do not resuscitate" directive while she was in the facility's care in 2016, the Albuquerque Journal reported.
>> Read more trending news
The lawsuit filed in New Mexico state district court against Santa Fe's Christus St. Vincent Regional Medical Center alleges that the hospital was negligent twice in its treatment of Jamie Sams, a writer known for her books about spirituality.

The lawsuit also alleges that Sams was given the painkiller Dilaudid, a medicine she claims she is allergic to, the Journal reported. Sams suffers from Dercum's, a rare disease that produces tumors all over the body, the newspaper reported.

According to court documents obtained by the Journal, Sams went into cardiac arrest after receiving the drug in the emergency room on Feb. 5, 2016, and the hospital's negligence was compounded when she was resuscitated -- something she did not want. Sams had signed a "Double DNR (do not resuscitate)" form, the newspaper reported.

"As a result of being revived, Plaintiff continues to experience severe pain, disability and limitations and further, will incur extensive expenses throughout the remainder of her life," the lawsuit against the hospital and emergency room doctor Jamie Gagan states. "This condition is extremely debilitating and painful and, moreover, requires frequent hospitalization and medication at great expense."

Christus spokesman Arturo Delgado told the Journal that Gagan works for HealthFront, which does emergency services work for the hospital. He said he could not comment on the lawsuit.

Sams is a Native American author who co-wrote "Medicine Cards: The Discovery of Power Through the Ways of Animals." According to her author biography on the Amazon website, she is a member of the Wolf Clan Teaching Lodge. Sams is half French and half American Indian, with ancestors from the Cherokee, Seneca, Choctaw, and Mohawk tribes according to her profile at Spirituality & Practice.

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New Mexico author sues hospital for reviving her

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A lawsuit filed on behalf of a New Mexico author alleges that a Santa Fe hospital revived the woman in violation of her "do not resuscitate" directive while she was in the facility's care in 2016, the Albuquerque Journal reported.

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Week 8 - do not resuscitate; what is the ethical problem? Get the facts. Consider the core ethical principles. Consider the different perspectives.

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Week 8 - do not resuscitate; what is the ethical problem? Get the facts. Consider the core ethical principles. Consider the different perspectives.

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Week 8 - women sues for reviving her; what is the ethical problem? Get the facts. Consider the core ethical principles. Consider the different perspectives.

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Week 8 - women sues for reviving her; what is the ethical problem? Get the facts. Consider the core ethical principles. Consider the different perspectives.

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A lawsuit filed on behalf of a New Mexico author alleges that a Santa Fe hospital revived the woman in violation of her "do not resuscitate" directive while she was in the facility's care in 2016, the Albuquerque Journal reported.
>> Read more trending news
The lawsuit filed in New Mexico state district court against Santa Fe's Christus St. Vincent Regional Medical Center alleges that the hospital was negligent twice in its treatment of Jamie Sams, a writer known for her books about spirituality.

The lawsuit also alleges that Sams was given the painkiller Dilaudid, a medicine she claims she is allergic to, the Journal reported. Sams suffers from Dercum's, a rare disease that produces tumors all over the body, the newspaper reported.

According to court documents obtained by the Journal, Sams went into cardiac arrest after receiving the drug in the emergency room on Feb. 5, 2016, and the hospital's negligence was compounded when she was resuscitated -- something she did not want. Sams had signed a "Double DNR (do not resuscitate)" form, the newspaper reported.

"As a result of being revived, Plaintiff continues to experience severe pain, disability and limitations and further, will incur extensive expenses throughout the remainder of her life," the lawsuit against the hospital and emergency room doctor Jamie Gagan states. "This condition is extremely debilitating and painful and, moreover, requires frequent hospitalization and medication at great expense."

Christus spokesman Arturo Delgado told the Journal that Gagan works for HealthFront, which does emergency services work for the hospital. He said he could not comment on the lawsuit.

Sams is a Native American author who co-wrote "Medicine Cards: The Discovery of Power Through the Ways of Animals." According to her author biography on the Amazon website, she is a member of the Wolf Clan Teaching Lodge. Sams is half French and half American Indian, with ancestors from the Cherokee, Seneca, Choctaw, and Mohawk tribes according to her profile at Spirituality & Practice.

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New Mexico author sues hospital for reviving her

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A lawsuit filed on behalf of a New Mexico author alleges that a Santa Fe hospital revived the woman in violation of her "do not resuscitate" directive while she was in the facility's care in 2016, the Albuquerque Journal reported.

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Week 7 - research study 2 (a syphilis study); explain how 1 bioethical principle that applies to protecting participants in this study?  How might the four bioethical principles be breached, therefore compromising the 

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Week 7 - research study 2 (a syphilis study); explain how 1 bioethical principle that applies to protecting participants in this study?  How might the four bioethical principles be breached, therefore compromising the 

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Week 7 - research study 1 (nuclear test explosions); explain how 1 bioethical principle that applies to protecting participants in this study?  How might the four bioethical principles be breached, therefore compromising the participants this study?

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Week 7 - research study 1 (nuclear test explosions); explain how 1 bioethical principle that applies to protecting participants in this study?  How might the four bioethical principles be breached, therefore compromising the participants this study?

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Week 7 - what are the potential risks or harms that may occur due to unethical research? 

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Week 7 - what are the potential risks or harms that may occur due to unethical research? 

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Week 7 - how might the four bioethical principles be breached, therefore compromising the participants in a study?

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Week 7 - how might the four bioethical principles be breached, therefore compromising the participants in a study?

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Week 7 - how do the four bioethical principles apply to protecting participants in a study?

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Week 7 - how do the four bioethical principles apply to protecting participants in a study?

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Week 7 - how can we ‘look after’ vulnerable communities/ populations when conducting a study?

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Week 7 - how can we ‘look after’ vulnerable communities/ populations when conducting a study?

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Week 7 - what are some examples of a vulnerable community/ population and what makes this group vulnerable?

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Week 7 - what are some examples of a vulnerable community/ population and what makes this group vulnerable?

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Week 6 - ethical decision making framework, scenario 3 (Bowler Ted). Provide your answers to your allocated question/s

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Week 6 - ethical decision making framework, scenario 3 (Bowler Ted). Provide your answers to your allocated question/s

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Week 6 - ethical decision making framework, scenario 2 (Paramedics on the scene). Provide your answers to your allocated question/s

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Week 6 - ethical decision making framework, scenario 2 (Paramedics on the scene). Provide your answers to your allocated question/s

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Week 6 - ethical decision making framework, scenario 1 (Mrs Abd-El-Kaderis). Provide your answers to your allocated question/s

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Week 6 - ethical decision making framework, scenario 1 (Mrs Abd-El-Kaderis). Provide your answers to your allocated question/s

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Week 6 - provide an example of an ethical dilemma that you have faced either in the health care setting OR in your work place. List which concept, principle, law and theory can you relate this to following your example.

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Week 6 - provide an example of an ethical dilemma that you have faced either in the health care setting OR in your work place. List which concept, principle, law and theory can you relate this to following your example.

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Week 5 - what does shared decision making mean to you, and what is an example of a lack of shared decision making in the healthcare environment?

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Week 5 - what does shared decision making mean to you, and what is an example of a lack of shared decision making in the healthcare environment?

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Week 5 - what does negligence mean to you, and what is an example of negligence not being upheld in the healthcare environment?

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Week 5 - what does negligence mean to you, and what is an example of negligence not being upheld in the healthcare environment?

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Week 5 - what does duty of care mean to you, and what is an example of duty of care not being upheld in the healthcare environment?

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Week 5 - what does duty of care mean to you, and what is an example of duty of care not being upheld in the healthcare environment?

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Week 5 - what does consent mean to you, and what is an example of consent not being upheld in the healthcare environment?

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Week 5 - what does consent mean to you, and what is an example of consent not being upheld in the healthcare environment?

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Week 4 - tips for maintaining professional boundaries 

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Week 4 - tips for maintaining professional boundaries 

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Week 4 - Universal Declaration of Human Rights - what is it? Comment below

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Week 4 - Universal Declaration of Human Rights - what is it? Comment below

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What is the Declaration of Human Rights? | 75 Years | United Nations | Narrated by Morgan Freeman

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Week 4 - which theory do you relate to most and why? Note the theory and one sentence outlining your 'why' below

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Week 4 - which theory do you relate to most and why? Note the theory and one sentence outlining your 'why' below

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Week 3 take home task - ethical reasoning

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Week 3 take home task - ethical reasoning

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-         Moral absolutists believe there is an absolute right way and an absolute wrong way – no middle ground.

-         Moral relativism is the idea that there are no absolute rules to determine whether something is right or wrong. Unlike moral absolutists, moral relativists argue that good and bad are relative concepts – whether something is considered right or wrong can change depending on opinion, social context, culture, or a number of other factors.

-         Moral pluralism: there are several values which may be equally correct and fundamental, and yet in conflict with each other. A pluralist strives to understand and respect all perspectives

REFLECTION: write a short reflection around which of the above you relate to most and why

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Theory of utilitarianism – the key points

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Theory of utilitarianism – the key points

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Utilitarianism is an ethical theory that determines right from wrong by focusing on outcomes.

Utilitarianism holds that the most ethical choice is the one that will produce the greatest good for the greatest number.

It is the only moral framework that can be used to justify military force or war.

Limitation: cannot predict the future.

Limitation: utilitarianism also has trouble accounting for values such as justice and individual rights

Limitation example: assume a hospital has four people whose lives depend upon receiving organ transplants: a heart, lungs, a kidney, and a liver. If a healthy person wanders into the hospital, his organs could be harvested to save four lives at the expense of one life. This would arguably produce the greatest good for the greatest number. But few would consider it an acceptable course of action, let alone the most ethical one.

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The common good definitions to consider 

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The common good definitions to consider 

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The common good is reached when we work together to improve the wellbeing of people in our society and the wider world.

Certain general conditions that are...equally to everyone's advantage.

The sum of those conditions of social life which allow social groups and their individual members relatively thorough and ready access to their own fulfillment.

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The belief that all people hold a special value that’s tied solely to their humanity. It has nothing to do with their class, race, gender, religion, abilities, or any other factor other than them being human.

A kind of basic worth or status that belongs to all persons equally, and which grounds fundamental moral or political duties or rights.

The dignity of every person, independent of ethnicity, creed, gender, sexuality, age or ability, is the foundation of Catholic Social Teaching. No human being should have their dignity or freedom compromised. Poverty, hunger, oppression and injustice make it impossible to live a life commensurate with this dignity.

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What would a society without ethics look like?

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Week 1: Professional standards - consider human dignity and the common good

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Week 1: Professional standards - consider human dignity and the common good

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Why is this all relevant to your profession?

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Twelve National Boards share a Code of conduct (the code) for the practitioners that they regulate.

The code describes the professional behaviour and conduct National Boards expect from registered health practitioners. By defining these expectations, the code supports good patient care and the delivery of services within an ethical framework, helping to keep the public safe.

Registered health practitioners have a responsibility to be familiar with and apply their relevant code.

The code has been revised so that it continues to be relevant and useful for practitioners, more accessible for health consumers and an effective and up-to-date regulatory tool.

The code applies to the practitioners regulated by the following National Boards:

Aboriginal and Torres Strait Islander Health Practice

Chinese medicine

Chiropractic

Dental

Medical radiation practice

Occupational therapy

Optometry

Osteopathy

Paramedicine

Pharmacy

Physiotherapy

Podiatry

The shared Code of conduct does not apply to the following professions:

Download the shared Code of conduct

Resources for health practitioners

Understanding the code's principles and what they mean in practice is important for health practitioners.

Here you will find information to help you understand and apply the code.
View resources

Resources for the public

Understanding the code helps the public know what to expect from their health practitioner.

Here you will find information to help you understand the code.
View resources

Code of conduct

Ahpra acknowledges the Traditional Owners of Country throughout Australia and their continuing connection to lands, waters and communities. We pay our respect to Aboriginal and Torres Strait Islander cultures and Elders past, present and emerging.

The 15 National Boards regulating registered health practitioners ¹ in Australia are responsible for registering practitioners and students, setting the standards that practitioners must meet, and managing notifications (complaints/concerns) about the health, conduct or performance of practitioners.

The Australian Health Practitioner Regulation Agency (Ahpra) works in partnership with the National Boards to implement the National Registration and Accreditation Scheme (the National Scheme), under the Health Practitioner Regulation National Law, as in force in each state and territory (the National Law).

The core role of the National Boards and Ahpra is to protect the public.

For a definition of registered health practitioners see the Definitions section.

The Code of conduct (the code) was developed by 12 National Boards under section 39 of the National Law to protect the public.

It sets out the standards of professional conduct the National Boards expect and is used by Boards to evaluate practitioners' conduct. Practitioners have a professional responsibility to be familiar with and to apply this code.

If you are receiving care or treatment from a registered health practitioner covered by this code, it will help you understand the behaviour you can expect.

Any person or organisation can raise a concern about a registered health practitioner by contacting Ahpra. Ahpra's website has more information about raising a concern about a health practitioner.

This code replaces the National Boards' previous code.

This code uses 'patient' ² to mean a person receiving healthcare from a registered health practitioner. The term 'patient' includes 'clients' and 'consumers'. Depending on the context of practice ³ and recognising the importance of patient-centred care, the term patient can also extend to families and carers (including kinship carers ⁴), and to groups and/or communities as users of health services.

See also the Definitions section of this code.

1. For a definition of patient see the Definitions section.

2. For a definition of practice see the Definitions section.

3. For a definition of kinship care see the Definitions section.

Principles

The following principles set out the National Boards' expectations of the practitioners they regulate.

1. Put patients first - Safe, effective and collaborative practice
Principle 1 - Practitioners should practise safely, effectively and in partnership with patients and colleagues, using patient-centred approaches, and informed by the best available evidence to achieve the best possible patient outcomes.

2. Aboriginal and Torres Strait Islander health and cultural safety
Principle 2 - Practitioners should consider the specific needs of Aboriginal and Torres Strait Islander Peoples and their health and cultural safety, including the need to foster open, honest and culturally safe professional relationships.

3. Respectful and culturally safe practice for all
Principle 3 - Respectful, culturally safe practice requires practitioners to have knowledge of how their own culture, values, attitudes, assumptions and beliefs influence their interactions with people and families, the community and colleagues. Practitioners should communicate with all patients in a respectful way and meet their privacy and confidentiality obligations including when communicating online.

4. Working with patients
Principle 4 - Basing relationships on respect, trust and effective communication enables practitioners to work in partnership with patients. Practitioners should maintain effective and professional relationships with their patients and provide explanations that enable patients to understand and participate in their care.

5. Working with other practitioners
Principle 5 - Good relationships with colleagues and other practitioners strengthen the practitioner-patient relationship, collaboration and enhance patient care. Good relationships require health care to be free of discrimination, bullying and harassment.

6. Working within the healthcare system
Principle 6 - Practitioners have a responsibility to contribute to the effectiveness and efficiency of the healthcare system and use resources wisely.

7. Minimising risk to patients
Principle 7 - Good practice involves putting patient safety, which includes cultural safety, first. Practitioners should minimise risk by maintaining their professional capability through ongoing professional development and self-reflection and understanding and applying the principles of clinical governance, risk minimisation and management in practice.

8. Professional behaviour
Principle 8 - Practitioners must display a standard of professional behaviour that warrants the trust and respect of the community. This includes practising ethically and honestly.

9. Maintaining practitioner health and wellbeing
Principle 9 - It is important for practitioners to maintain their health and wellbeing. This includes seeking an appropriate work-life balance.

10. Teaching, supervising and assessing
Principle 10 - Practitioners should support the important role of teaching, supervising and mentoring practitioners and students in order to develop the health workforce.

11. Ethical research
Principle 11 - Practitioners should recognise the vital role of ethical and evidence-based research to inform quality healthcare and policy development, conduct research ethically and support the decision-making of research participants.

This code sets out National Boards' expectations about professional behaviour and conduct for registered health practitioners. In the context of the practitioner-patient relationship, practitioners have a duty to put the care of patients first and to practise safely and effectively. Maintaining a high level of professional competence and conduct is essential for good care.

There are many ways to practise a health profession in Australia. Practitioners have critical roles in caring for people who are unwell, helping people to recover, and seeking to keep people well. This code covers these roles. For practitioners with roles that involve little or no contact with patients, not all of this code may be directly relevant, but the underpinning principles will still apply.

While individual practitioners have their own personal beliefs and values, there are certain professional values on which all practitioners are expected to base their practice. The professional values and behaviours in this code apply to practitioners' conduct in every setting, including in-person, during technology-based consultations including online and remote prescribing, and electronically, e.g. social media ⁵, digital health and so on.

The code includes 11 principles of conduct. Each principle is followed by practical information about how to apply it in practice. Underpinning the code is the expectation that practitioners will use their professional judgement to achieve the best possible outcomes in practice.

Purpose of the code

This code is a principles-based document that gives important guidance to practitioners about the National Boards' expectations of their professional conduct and outlines the conduct that the public can expect from health practitioners. It is a key part of the regulatory framework that each National Board establishes for the profession(s) it regulates in order to protect the public and progress the other objectives of the National Law. By defining National Boards' expectations of professional conduct, the code supports patients' interests, good patient care and the delivery of appropriate, effective services within an ethical framework.

Scope of the code

This code:

describes and reinforces the professional conduct that most registered health practitioners already demonstrate

provides a framework for professional conduct and supports individual practitioners in the challenging task of providing good healthcare and fulfilling their professional roles

assists National Boards in their regulatory role by setting and maintaining principles and standards of good practice - Boards will use this code when evaluating practitioners' professional conduct.⁶ If professional conduct varies significantly from this code, practitioners should be prepared to explain and justify their decisions and actions. Serious or repeated failure to meet this code may lead to patient harm and have consequences for registration

is a resource to help enhance the culture of professionalism in the Australian health system: for example, in practitioner education; orientation, induction and supervision of students; and by administrators and policy makers in hospitals, health services and other institutions, and

is a guide to the public and health service users about what good practice is and the conduct they should expect from health practitioners.

The code is also a reference for co-regulatory authorities about the standards of professional conduct that National Boards expect.

What this code does not do

Practitioners must understand their legal obligations and always act in accordance with the law in their personal and professional lives. The code is not a substitute for legislation and case law, e.g. privacy, child protection, medicines and workplace health and safety laws. If there is any conflict between the code and the law, the law takes precedence. Practitioners must also be aware of and meet the other standards, guidelines and policies of their National Board, which this code complements.

This code is not an exhaustive study of professional ethics or an ethics guide. It articulates the National Boards' expectations about ethical and professional conduct, but not the standards of clinical practice within individual health professions or disciplines. These clinical standards are generally found in other documents issued by the relevant National Boards and/or professional bodies.

While good healthcare respects the rights of patients, this code is not a charter of rights. ⁷ The focus of this code is on good practice and professional behaviour. It is not intended as a mechanism to address:

1. disputes between professional colleagues, e.g. in relation to termination of business relationships and disputes over patients, or

2. employment issues e.g. workplace or industrial disputes, which do not raise broader patient safety concerns.

Professional values and qualities

When providing care, practitioners have a duty to make patient care their first concern and to practise safely and effectively. Professionalism embodies all the qualities described below, including self-awareness and self-reflection. These qualities underpin and are further explained in the guidance provided throughout the code.

1. Good practice is centred on patients. It involves practitioners understanding that each patient is unique and working in partnership with patients, adapting what they do to address the needs and reasonable expectations of each person. This includes cultural awareness: being aware of their own culture and beliefs, being respectful of the beliefs and cultures of others and recognising that these cultural differences may affect the practitioner-patient relationship and the provision of services. As well as avoiding discrimination, good practice also includes being aware that differences such as gender, sexuality, age, belief systems and other attributes may influence care needs.

2. Effective communication in all forms underpins every aspect of good practice.

3. Practitioners must be ethical and trustworthy. Patients trust practitioners because they believe that, in addition to being competent, practitioners will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion. Patients also rely on practitioners to protect their confidentiality.

4. Practitioners have a responsibility to protect and promote the health of individuals and the community.

5. Practitioners are expected to reflect regularly on whether they are practising safely and effectively, on their relationships with patients and colleagues, and on their own health and wellbeing.

6. Practitioners have a duty to keep their skills and knowledge up to date, refine and develop their clinical judgement as they gain experience, and contribute to maintaining public confidence in the profession.

7. Scopes of practice vary according to different roles; for example, practitioners, researchers and managers will all have different scopes of practice. Practitioners have a responsibility to recognise and work within the limits of their skills and competence.

8. Practitioners should be committed to safety and quality in healthcare.⁸

Substitute decision-makers

In this code, reference to 'patients' also includes substitute decision-makers e.g. for patients who do not have the capacity to make their own decisions. These can be parents, guardians, a person nominated by the patient or a legally appointed decision-maker. If in doubt, seek advice from the relevant guardianship authority.

1. For a definition of social media see the Definitions section.

2. Under section 41 of the National Law the code may be used to evaluate a practitioner's professional conduct when a notification (complaint) is made about them, as one of a range of relevant factors taken into account on a case-by-case basis.

3. An example of a charter of rights is the Australian charter of healthcare rights issued by the Australian Commission on Safety and Quality in Health Care (ACSQHC).

4. See the ACSQHC, the National Safety and Quality Health Service Standards, and the References section at the end of this code.

Principle 1: Practitioners should practise safely, effectively and in partnership with patients and colleagues, using patient-centred approaches, and informed by the best available evidence to achieve the best possible patient outcomes.

1.1 Providing good care

Patient care is your primary concern in clinical practice. Providing good care includes that you:

1.2 Good care

Maintaining a high level of professional competence and conduct is essential for good care.

Good practice includes that you:

1. ensure you maintain adequate knowledge and skills to provide safe and effective care⁹

2. ensure that, when moving into a new area of practice, you have sufficient training and/or qualifications to achieve competency in that new area

3. maintain adequate records (see Section 8.3 Health records)

4. consider the balance of potential benefit and harm in all clinical management decisions

5. communicate effectively with patients to ensure they have enough information to make an informed decision about their current and future care and respect their decision if they choose no treatment or care (see Section 3.2 Effective communication)

6. provide treatment options that are based on the best available information and are not influenced by financial gain or incentives

7. practise within an evidence-based and patient-centred framework

8. take steps to alleviate the symptoms and distress of patients, whether a cure is possible or not

9. support the right of the patient to seek a second opinion

10. respond to adverse events and implement the principles of open disclosure (see Section 4.5 Adverse events and open disclosure)

11. consult and take advice from colleagues when appropriate

12. make responsible and effective use of the resources available to practitioners (see Section 6.1 Use healthcare resources wisely)

13. ensure that your personal views do not adversely affect the care of a patient

14. reflect on your practice and your decisions and actions in providing good and culturally safe care, and

15. facilitate the quality use of therapeutic products based on the best available evidence and the patient's needs.

1.3 Decisions about access to care

Your decisions about access to care must be free from bias and discrimination. ¹⁰

Good practice includes that you:

1.4 Treatment in emergencies

Treating patients in emergencies requires practitioners to consider a range of issues, in addition to providing best care. Good practice means you should offer assistance in an emergency that takes account of factors such as your own safety, your skills, the availability of other options and the impact on any other patients under your care, and continue to help until your services are no longer needed.

1. You should refer to your National Board's Continuing professional development registration standard and Recency of practice registration standard.

2. For a definition of discrimination see the Definitions section.

Principle 2: Practitioners should consider the specific needs of Aboriginal and Torres Strait Islander Peoples and their health and cultural safety, including the need to foster open, honest and culturally safe professional relationships.

2.1Aboriginal and/or Torres Strait Islander health

Aboriginal and Torres Strait Islander Peoples have inhabited and cared for the land as the First Peoples of Australia for millennia, and their diverse histories and cultures have uniquely shaped our nation. Aboriginal and Torres Strait Islander health means not just the physical wellbeing of an individual but refers to the social, emotional and cultural wellbeing of the whole community in which each individual is able to achieve their full potential as a human being, thereby bringing about the total wellbeing of their community. It is a whole-of-life view and includes the cyclical concept of life-death-life. ¹¹

Understanding and acknowledging factors such as colonisation and its impact on Aboriginal and Torres Strait Islander Peoples' health, helps inform care. In particular, Aboriginal and Torres Strait Islander Peoples bear the burden of gross social and health inequity. It is for these reasons that cultural safety in the context of Aboriginal and Torres Strait Islander health needs to be specifically considered.

2.2Cultural safety for Aboriginal and Torres Strait Islander Peoples

Supporting good practice and the health of Aboriginal and Torres Strait Islander Peoples also includes cultural safety. For Aboriginal and Torres Strait Islander Peoples, the National Scheme's definition of cultural safety is as follows:
Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities. Culturally safe practice is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism.
To ensure culturally safe and respectful practice, you must:

See the Australian Government's National Aboriginal and Torres Strait Islander Health Plan 2013-2023 and the National Safety and Quality Health Service Standards User guide for Aboriginal and Torres Strait Islander health.

National Aboriginal Health Strategy Working Party 1989, National Aboriginal Health Strategy, Canberra.

Principle 7: Good practice involves putting patient safety, which includes cultural safety, first. Practitioners should minimise risk by maintaining their professional capability through ongoing professional development and self-reflection and understanding and applying the principles of clinical governance, risk minimisation and management in practice.

7.1Risk management

Good practice in relation to risk management includes that you:

1. practise cultural safety as detailed in Sections 2 and 3

2. understand the importance of clinical governance²⁹ and your obligations, where relevant

3. participate in quality assurance and improvement systems where available

4. develop and implement risk management processes that identify and minimise risk to reduce harm to patients³⁰ and/or to respond to adverse events, if you practise in a setting where local systems are not in place

5. participate in systems for surveillance and monitoring of adverse events and 'near misses', including reporting such events to the relevant authority where applicable

6. ensure systems are in place for raising concerns about risks to patients, if you have clinical leadership/management responsibilities

7. work to reduce error and improve patient safety, including within available systems

8. support colleagues who raise concerns about the safety of patients, and

9. take all reasonable steps to address the issue if there is reason to think that the safety of patients may be compromised.

7.2Practitioner performance

The welfare of patients may be put at risk if a practitioner is performing poorly.

If there is a risk, good practice includes that you:

1. recognise and take steps to minimise the risks of fatigue, including complying with relevant state and territory occupational health and safety legislation

2. follow the guidance in Section 9.1 Your health if you know or suspect that you have a health condition that could adversely affect your judgement or performance

3. take steps to protect patients from being placed at risk of harm posed by a colleague's conduct, practice or ill health (see Section 9.2 Other practitioners' health)

4. comply with statutory reporting requirements, including mandatory notifications requirements under the National Law

5. take appropriate steps to assist a colleague to get help if you have concerns about their performance or fitness to practise, and

6. seek advice from an experienced colleague, your employer/s, practitioner health advisory services, professional indemnity insurers, the National Boards/Ahpra or a professional organisation if you are not sure what to do.

7.3Maintaining and developing professional capability

Maintaining and developing appropriate and current knowledge, skills and professional behaviour are core aspects of good, culturally safe practice, requiring self-reflection and participation in relevant professional development, practice improvement and performance-appraisal processes to continually develop professional capabilities. These activities must continue through a practitioner's working life as science and technology develop and society changes.

7.4Continuing professional development (CPD)

Development of knowledge, skills and professional behaviour must continue throughout a practitioner's working life. Good practice involves you keeping knowledge and skills up to date to ensure that you continue to work within your competence and scope of practice. The National Law requires practitioners to do CPD. ³¹

1. For a definition of clinical governance see the Definitions section. For additional information see ACSQHC National Model Clinical Governance Framework and ACSQHC Clinical Governance Standard.

2. See ACSQHC NSQHS Standards Risk Management Approach.

3. Refer to your National Board's registration standard and guidelines on CPD for details of these requirements.

Principle 8: Practitioners must display a standard of professional behaviour that warrants the trust and respect of the community. This includes practising ethically and honestly.

8.1Reporting obligations

Practitioners have statutory responsibility under the National Law to report certain matters to the National Boards/Ahpra: please refer to the Board's guidelines on mandatory notifications and Sections 130 and 141 of the National Law. Practitioners also have professional obligations to report to the National Boards/Ahpra and their employer/s if they have had any limitations placed on their practice.

Good practice includes that you:

1. are aware of these reporting obligations

2. comply with any reporting obligations that apply to your practice, and

3. seek advice from your National Board, professional indemnity insurer or other relevant bodies if you are unsure about your obligations.

For additional information see Making a mandatory notification on Ahpra's Concerns about practitioners webpage.

8.2Vexatious notifications (complaints/concerns)

A vexatious notification ³² (complaint/concern)is one without substance, made with an intent to cause distress, detriment or harassment to a practitioner named in the notification. Legitimate notifications (complaints/concerns) are motivated by genuine concerns about patient safety.

Good practice includes that you:

1. raise genuine concerns about risks to patient safety to the appropriate authority (locally and/or the relevant National Board) and comply with mandatory notifications requirements, and

2. do not raise notifications (complaints/concerns) that are vexatious or not in good faith about other health practitioners. These claims may be viewed as unprofessional conduct or professional misconduct and the Board may take regulatory action.

8.3Health records

Maintaining clear and accurate health records is essential for the continuing good care of patients. You should be aware that some National Boards have specific guidelines in relation to records.

Good practice includes that you:

1. keep accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners

2. ensure that records are held securely and are not subject to unauthorised access. This includes protecting the privacy and integrity of electronic records

3. ensure that records show respect for patients and do not include demeaning or derogatory remarks

4. ensure that records are sufficient to facilitate continuity of care

5. make records at the time of events or as soon as possible afterwards

6. recognise the right of patients to access information contained in their health records and facilitate that access, and

7. promptly facilitate the transfer or management (including disposal) of health information in accordance with legislation on privacy and health records when requested by patients, or when closing or relocating a practice.

8.4Insurance

You have a statutory requirement to ensure that you have appropriate professional indemnity insurance (PII) arrangements in place when you practise (see your National Board's Professional indemnity insurance arrangements registration standard).

8.5Advertising

Advertisements for services can provide useful information to patients. However, advertising should not be false, misleading or deceptive, use testimonials about clinical aspects of a regulated health service, create an unreasonable expectation of benefit or encourage the indiscriminate or unnecessary use of regulated health services. Advertising that offers a gift, discount or other inducement to attract someone to use the regulated health service or business must state the offer's terms and conditions in plain language.

Good practice involves complying with the advertising requirements of the National Law (explained in the National Boards' Guidelines for advertising a regulated health service) and relevant Commonwealth, state and territory legislation on consumer protection, fair trading and therapeutic goods advertising, and ensuring that any promotion of therapeutic products is ethical.

8.6Legal, insurance and other assessments

When you are contracted by a third party to provide a legal, insurance or other assessment of a person who is not your patient, the usual therapeutic practitioner-patient relationship does not exist. In this situation, good practice includes that you:

1. apply the standards of professional behaviour described in this code to the assessment; in particular, be respectful, alert to the concerns of the person and ensure the person's consent

2. explain to the person your area of practice, role and the purpose, nature and extent of the assessment to be conducted

3. anticipate and seek to correct any misunderstandings the person may have about the nature and purpose of your assessment and report

4. provide an impartial report (see Section 8.7 Reports, certificates and giving evidence), and

5. recognise that if you discover an unrecognised, serious health issue during the assessment, you have a duty of care to inform the patient or their treating practitioner.

8.7Reports, certificates and giving evidence

The community places a great deal of trust in registered health practitioners. Consequently, some practitioners have been given the authority to sign documents such as sickness or fitness for work certificates on the assumption that they will only sign statements that they know, or reasonably believe, to be true.

Good practice includes that you:

8.8Your work history

When providing information about your work history, good practice includes that you:

1. provide accurate, truthful and verifiable information about your work history, experience and qualifications, and

2. do not misrepresent by misstatement or omission your work history, experience, qualifications or position.

Also see Section 10.2 Assessing colleagues in relation to providing references for colleagues.

8.9Investigations

Practitioners have responsibilities and rights relating to any legitimate investigation of their practice or that of a colleague. In meeting these responsibilities, it is advisable to seek legal advice or advice from a professional indemnity insurer.

Good practice includes that you:

8.10Conflicts of interest

Patients rely on the independence and trustworthiness of practitioners for any advice or treatment offered. A conflict of interest in practice arises when a practitioner, entrusted with acting in the interests of a patient, also has financial, professional or personal interests or relationships with third parties which may affect or be perceived to affect their care of the patient.

Multiple interests are common. They require identification, careful consideration, appropriate disclosure and accountability. When these interests compromise or might reasonably be perceived by an independent observer to compromise the practitioner's primary duty to the patient, practitioners must recognise and resolve this conflict in the best interests of the patient.

Good practice includes that you:

1. recognise potential conflicts of interest that may arise in relation to initiating or continuing a professional relationship with a patient

2. act in the best interests of your patients when making referrals, and when giving or arranging treatment or care

3. inform your patients when you have an interest that could affect or could be perceived to affect patient care

4. recognise that pharmaceutical and other marketing may influence practitioners, and avoid your practice being adversely influenced by marketing

5. do not ask for or accept any inducement, gift or hospitality from companies that sell or market pharmaceuticals or other products that may affect or be seen to affect the way you prescribe for, treat or refer patients

6. do not ask for or accept fees for meeting sales representatives

7. do not offer inducements to colleagues or enter into arrangements that could be perceived to provide inducements

8. do not allow any financial or commercial interest in a hospital, pharmacy, other healthcare organisation or company providing healthcare services or products to adversely affect the way in which patients are treated. When you or your immediate family have such an interest and that interest could be perceived to influence the care provided, you must inform your patients, and

9. if you employ other registered health practitioners, do not set performance targets, quotas or engage in business practices that are inconsistent with this code, and/or may compromise patient safety.

8.11Financial and commercial dealings

Practitioners must be honest and transparent in financial arrangements with patients.

Good practice includes that you:

1. do not exploit the vulnerability or lack of knowledge of patients when providing or recommending services

2. do not influence patients to give, lend or bequeath money or gifts that will benefit you directly or indirectly

3. do not pressure patients to make donations to other people or organisations

4. do not accept gifts from patients other than tokens of minimal value such as flowers or chocolates, and, if you do accept a token gift, make a file note or inform a colleague if possible

5. do not become involved financially with patients; for example, through loans and investment schemes, and

6. be transparent in financial and commercial matters relating to work, including dealings with employers, insurers and other organisations or individuals, and in particular:

declare any relevant and material financial or commercial interest that you or your family might have in any aspect of the care of the patient, and

declare to patients any professional and financial interest in any product or service you might endorse or sell from your practice, and do not make an unjustifiable profit from the sale or endorsement.

For a definition of vexatious notification see the Definitions section

Principle 9: It is important for practitioners to maintain their health and wellbeing. This includes seeking an appropriate work-life balance.

9.1 Your health

Good practice includes that you:

1. attend a general practitioner or other appropriate practitioner to meet your health needs

2. seek expert, independent, objective advice when you need healthcare, and be aware of the risks of self-diagnosis and self-treatment

3. understand the importance of immunisation against communicable diseases and take appropriate precautions to limit the spread of infectious diseases to yourself and others

4. are immunised against any relevant communicable diseases

5. conform to the relevant state/territory legislation on self-prescribing, if you can prescribe

6. recognise the impact of fatigue and the risks associated with long working hours on your health and ability to care for patients safely

7. be aware of and seek assistance from any relevant practitioner health program if advice or help is needed, and

8. do not rely on your own assessment of the risk you pose to patients if you know or suspect that you have a health condition or impairment that could adversely affect your judgement, performance or the health of patients. In this case:

consult a medical or other practitioner as appropriate about whether, and in what ways, you may need to modify practice, and follow the treating practitioner's advice, and

be aware of your responsibility under the National Law to notify the National Boards/Ahpra in relation to certain impairments.

9.2Other practitioners' health

Health practitioners have a responsibility to help their colleagues maintain good health.

Good practice includes that you:

1. give practitioners who are patients the same quality of care provided to other patients

2. take action, including a mandatory or voluntary notification to Ahpra, if you know or reasonably believe that a registered health practitioner is putting patients at risk of harm by practising with an impairment. The Ahpra website has further information on raising concerns about a practitioner via a voluntary notification, and the thresholds for making a mandatory notification in the Guidelines: Mandatory notifications about registered health practitioners

3. recognise the effect of fatigue on the health of colleagues, including those under supervision, and facilitate safe working hours wherever possible.

Principle 10: Practitioners should support the important role of teaching, supervising and mentoring practitioners and students in order to develop the health workforce.

10.1Teaching and supervising

In teaching and supervision roles, good practice includes that you:

10.2Assessing colleagues

Assessing colleagues is an important part of making sure that the highest standards of practice are achieved.

Good practice includes that you:

1. are honest, objective, constructive and culturally safe when assessing the performance of colleagues, including students, and do not put patients at risk by inaccurate or inadequate assessment, and

2. provide accurate and justifiable information promptly and include all relevant information when giving references or writing reports about colleagues.

10.3Students

Students are learning how best to care for patients. Creating opportunities for learning improves their clinical practice and nurtures the future workforce.

Good practice includes that you:

Principle 11: Practitioners should recognise the vital role of ethical and evidence-based research to inform quality healthcare and policy development, conduct research ethically and support the decision-making of research participants.

Research involving humans, their tissue samples or their health information is vital to improve the quality of healthcare and reduce uncertainty for patients now and in the future, and to improve the health of the population as a whole. Research in Australia is governed by guidelines issued in accordance with the National Health and Medical Research Council Act 1992 (Cth) and any other legislative requirements. If you are carrying out research, you should familiarise yourself with and follow these guidelines.

Research involving animals is governed by legislation in states and territories and by guidelines issued by the National Health and Medical Research Council (NHMRC).

11.1Research ethics

Being involved in the design, organisation, conduct or reporting of health research involving humans brings responsibilities for practitioners. These responsibilities include that you:

1. accord to participants the respect and protection that is due to them

2. act with honesty and integrity

3. ensure that any protocol for human research has been approved by a human research ethics committee, in accordance with the National Statement on Ethical Conduct in Human Research issued by the NHMRC (which addresses privacy issues, and refers to the need to consider relevant state, territory and federal privacy legislation)

4. disclose the sources and amounts of funding for research to the human research ethics committee

5. disclose any potential or actual conflicts of interest to the human research ethics committee

6. ensure that human participation is voluntary and based on informed consent and an adequate understanding of sufficient information about the purpose, methods, demands, risks and potential benefits of the research

7. ensure that any dependent relationship between practitioners and their patients is taken into account in the recruitment of patients as research participants

8. seek advice when research involves children or adults who are not able to give informed consent to ensure that there are appropriate safeguards in place, including ensuring that a person empowered to make decisions on the behalf of patients has given informed consent, or there is other lawful authority to proceed

9. adhere to the approved research protocol

10. monitor the progress of the research and report adverse events or unexpected outcomes promptly

11. respect the entitlement of research participants to withdraw from any research at any time and without giving reasons

12. adhere to the guidelines regarding publication of findings, authorship and peer review, and

13. report possible fraud or misconduct in research as required under the Australian Code for the Responsible Conduct of Research issued by the NHMRC.

Refer to the NHMRC, including the publications listed above, for more guidance including about ethical conduct in research with Aboriginal and Torres Strait Islander Peoples and communities.

11.2Treating practitioners and research

When you are involved in research that involves patients, good practice includes that you:

1. respect the right of patients to withdraw from a study without prejudice to their treatment, and

2. ensure that a decision by patients not to participate does not compromise the practitioner-patient relationship or the care of the patient.

Bullying is when people repeatedly and intentionally use words or actions against someone or a group of people to cause distress and risk to their wellbeing. These actions are usually done by people who have more influence or power over someone else, or who want to make someone else feel less powerful or helpless (Australian Human Rights Commission - What is bullying?: Violence, harassment and bullying fact sheet).

Clinical governance describes a systematic approach to maintaining and improving the quality of patient care within a clinical setting. It ensures that everyone - from frontline clinicians to managers and members of governing bodies, such as boards - is accountable to patients and the community for assuring the delivery of safe, effective and high-quality services.

Complaint is a way to raise a concern about a registered practitioner. Ahpra and the National Boards' main role is to protect the public by ensuring that only health practitioners who are suitably trained and qualified, and who practise in a competent and ethical manner, are registered. This means that we can only investigate the concern if there may be a risk to the public. Other organisations have a different purpose and are set up to resolve a dispute or complaint between a health service user (such as a patient) and a health service provider (such as a hospital, clinic or a health practitioner). More detailed information is published on Ahpra's Concerns about practitioners page.

Cultural safety

This definition of cultural safety was developed for use in the National Scheme by the Scheme's Aboriginal and Torres Strait Islander Health Strategy Group in partnership with the National Health Leadership Forum.
Principles
The following principles inform the definition of cultural safety:
Definition
Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities.

Culturally safe practice is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism.

Delegation involves one practitioner asking another person or member of staff to provide care on behalf of the delegating practitioner, while that practitioner retains overall responsibility for the care of the patient.

Discrimination occurs when a person, or a group of people, is treated less favourably than another person or group because of their background or certain personal characteristics ( Australian Human Rights Commission).

Electronic means any digital form of communication, including email, online meeting technologies, internet, social media, etc.

Handover is the process of transferring all responsibility for a patient's care to another practitioner.

Harassment - to treat a person less favourably on the basis of certain personal characteristics, such as race, sex, pregnancy, marital status, breastfeeding, age, disability, sexual orientation, gender identity or intersex status ( Australian Human Rights Commission).

Kinship care is family-based care within the child's extended family or with close friends of the family known to the child, whether formal or informal in nature (United Nations, 2010).

Notification is the way to raise a concern about a registered practitioner's professional conduct, performance, or health. Ahpra and National Boards' main role is to protect the public by ensuring that only health practitioners who are suitably trained and qualified, and who practise in a competent and ethical manner, are registered. This means that we can only investigate the concern if there may be a risk to the public. We call these concerns notifications. Other organisations have a different purpose and are set up to resolve a dispute or complaint between a health service user (such as a patient) and a health service provider (such as a hospital, clinic or a health practitioner). More detailed information is published on Ahpra's Concerns about practitioners page.

Providing care includes, but is not limited to, any care, treatment, examination, advice, service or goods provided in respect of the physical or mental health of a person, whether remunerated or pro bono.

Practice means any role, whether remunerated or not, in which the individual uses their skills and knowledge as a practitioner in their regulated health profession. For the purposes of this code, practice is not restricted to the provision of direct clinical care. It also includes using professional knowledge in a direct non-clinical relationship with patients, working in management, administration, education, research, advisory, regulatory or policy development roles and any other roles that have an impact on safe, effective delivery of health services in the health profession.

Patient means a person who has entered into a therapeutic and/or professional relationship with a registered health practitioner. The term 'patient' includes 'clients' and 'consumers'. It can also extend to their families and carers (including kinship carers), and to groups and/or communities as users of health services, depending on context.

Practitioner means registered health practitioner (see below).

Racism includes prejudice, discrimination or hatred directed at someone because of their colour, ethnicity or national origin.

Referral involves one practitioner sending a patient to obtain an opinion or treatment from another practitioner. Referral usually involves the transfer (in part) of responsibility for the care of the patient, usually for a defined time and a particular purpose, such as care that is outside the referring practitioner's expertise or scope of practice.

Registered health practitioner (practitioner) means an individual who is registered under the National Law to practise a health profession, other than as a student; or who holds non-practising registration in a health profession under the National Law.

Sexual harassment is broadly defined as unwelcome sexual conduct that a reasonable person would anticipate would offend, humiliate or intimidate the person harassed (Australian Human Rights Commission, 2014).

Social media describes the online and mobile tools that people use to share opinions, information, experiences, images, and video or audio clips, and includes websites and applications used for social networking. Common sources of social media include, but are not limited to, social networking sites such as Facebook and LinkedIn, blogs (personal, professional and those published anonymously), business search and review sites such as Word of Mouth and True Local, microblogs such as Twitter, content-sharing websites such as YouTube and Instagram, and discussion forums and message boards. For the purposes of this code, practice is not restricted to the provision of direct clinical care. For more information see Social media: How to meet your obligations under the National Law.

Vexatious notification is a notification without substance, made with an intent to cause distress, detriment or harassment to a practitioner named in the notification. Vexatious notifications can come from anyone including patients, members of the public and other practitioners.

Date of issue: June 2022

Date of review: This Code of conduct will be reviewed from time to time as needed. This is generally at least every five years.

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australian health practitioner regulation agency

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Australian Health Practitioner Regulation Agency

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Week 1: Theory of utilitarianism – the key points

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Week 1: Theory of utilitarianism – the key points

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Week 1: What are some buzz words that come to mind when you think about ‘the common good’?

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Week 1: What are some buzz words that come to mind when you think about ‘human dignity’?

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Week 1: Experience Reflection Action, 'ERA' model