Healthcare ethics for Healthcare Practitioners

Front matter

HEALTHCARE

ETHICS FOR HEALTHCARE PRACTITIONERS sb

Published by Sun Media Bloemfontein (Pty) Ltd.

Chapter 2: Unpacking vulnerability in healthcare ethics … nn. 11 Laetus 0.K. Lategan

Chapter 3: The difference between right and WrONg eere. 21 Gert J. van Zyl and Paulina van Zyl

Linus Vanlaere & Roger Burggraeve

Joyce MacKinnon and Amber Comer

André Moore

Chapter 7: Euthanasia, do we dare? … nana ananeenene ener tnn tena nes 73 Charné Viljoen

Chapter 8: Community-based participatory research in healthcare: ethical issues

Moira S. Lewitt, Pamela Campbell and Beth Cross

Willem H. Kruger

Chapter 10: Spirituality and healthcare … an aeanneneneneenenenennsneneneneenn 113 Marius Swart

“To understand medicine better, therefore, we need to explore the way in which science functions, and to confront the technologically-based world”

D.G. Jones

ORIENTATION

The need for healthcare ethics

Laetus O.K. Lategan and Gert J. van Zyl

THE NEED FOR HEALTHCARE ETHICS

1. BACKGROUND TO THE BOOK PROJECT

The debate on and interest in ethical challenges in healthcare is not new. Evidence for this comment can be found in (the earliest) recorded medical-ethical codes such as the Hippocratic, Helsinki and Geneva Codes. These codes are further supplemented by reports from the World Healthcare Organisation (WHO) and a continuous debate on how best to provide healthcare in a global environment. The challenge is well described by Ten Have (2011) who identifies the different meanings attached to bioethics in different countries and different health systems because of technological developments, socio-economic needs and developments stimulated through business and industry partnerships (especially pharmacology).

A common observation deriving from these codes, reports and debates is the ethical vulnerability from which healthcare practitioners are currently suffering. As a result of ethical vulnerability, healthcare practitioners often find it hard to deliver quality-based healthcare.

Ethical vulnerability is closely associated with four dominant influences on healthcare. These influences are:

m Healthcare is unthinkable without modern technology. Thanks to technology, the so-called "machbarkeit aller dinge" influences healthcare practices. Three different opinions portray the impact technology has on healthcare: Consider the following opinions: We should not do everything that we are able to do (Jan-Hendrik van den Berg, 1969); we should do everything we can do (R. du Jardin) and technology is in service of life (Echbert Schuurman, 1995).

m Medical economy (medical industry): The pharmaceutical industry sparks questions with regard to medical insurance and business ethics. The question is correctly asked: What is at stake: health improvement or profit margins? This is closely related to consumerism in healthcare. Typical debates are around needs versus wants in healthcare, substitution, replacement and make-over.

m The democratising of healthcare systems: Equality and access to basic health and healthcare systems open challenges such as affordability, necessity and quality. At the same time a debate on e-medicine, e-health and tele-medicine is opened.

m Slow living as a contra culture: Slow living is a post-materialistic culture advocating a return to a holistic lifestyle, and looking at how we live and what we consume. It advocates sustainability of communities, happiness (“the real good life") and harmony between people and their habitat (as collective for work, home and social networks, interaction and support).

Ethical vulnerability necessitates a new understanding of healthcare ethics; its meaning(s) and application(s). In addition, a post-religious and post-structural world together with a technologicaldriven society, require a new understanding of the healthcare environment.

Healthcare ethics is trans-disciplinary of nature and transcends the common dictums of do no harm, do to others as to yourself and be your brother/sister's keeper. Healthcare ethics calls on stewardship ethics where you care for something as if you own it. In addition, healthcare ethics is challenged through questions such as: are we caring for patients because of a social contract between healthcare worker and patient? human and constitutional rights? humanitarian or religious conviction and/or professional calling?

It should be obvious that (healthcare) ethics is more than moral behaviour (expected reactions and behaviour) orthe application of norms and standards. Healthcare ethics depends on a cosmological understanding of ethics [Kobus (J.H.) Smit, 1985], informed decisions (Joseph Badaracco, 1998), responsible acts (Joachim Douma, 1999), ethical relations (Paul Schotmans, 2012) and ethical growth (Roger Burggraeve, 1997).

2. OBJECTIVE OF THIS BOOK

This book promotes the argument that modern day healthcare ethics cannot be limited in scope to apply only to the patient but needs to apply to the healthcare practitioner as well. Healthcare practitioners include doctors, professional nurses and therapists. The relationship between the patient and the healthcare practitioner has shifted from a power relationship (the healthcare practitioner has the knowledge and skillto cure, care, heal, support and comfort) to a complementary relationship (mutual respect, acknowledgement of individual interests). Leadership, mentorship and coaching play an important role in facilitating this shift.

In the debate on healthcare ethics we need to consider questions relating to: the preservation of life; the uniqueness of people, their personal values, faith and traditions; the protection of dignity, welfare, personal security or safety; freedom of choice and informed consent; the enhancement of basic medical care; affordability, economies of scale and consumerism; professional attitude and patient privacy, shared information on therapies; potential risk and value of therapies and treatment, coaching, leadership and mentorship.

3. OUTLINE OF THE BOOK

Several themes informed this book on healthcare ethics. The themes are:

m Vulnerability in healthcare ethics m Decisions between right and wrong m Quality of care m Life-ending decisions

THE NEED FOR HEALTHCARE ETHICS m Research involving the community m Making ethical choices m= Spirituality in healthcare

The focus of the book is to contribute towards a new understanding of healthcare ethics and how to deal with healthcare practitioners’ ethical vulnerability in a post-religious, post-structural, technology-informed and human rights-driven society.

This book suggests guidelines to the patient and healthcare practitioner and invites an engaged dialogue between patients, healthcare practitioners, healthcare managers and administrators, and habitats supporting the people working in healthcare and the people who benefit from healthcare.

Badaracco, J.L. 1998. Business ethics: roles and responsibilities. St Louis: McGraw-Hill.

Burggraeve, R. 1997. Een christelijke ethiek van het haalbare. In Wuyts, B. (red.). De geest rust nooit: Gelovigen in beweging. Kapellen: Patmos. 143-152.

Douma, J. 1999. Grondslagen christelijke ethiek. Kampen: Uitgeverij Kok. Schotsmans, P 2012. In goede handelen. Tielt: Lannoo.

Schuurman, E. 1995. Perspectives on technology and culture. Potchefstroom: IRS. Smit, J.H. 1985. Etos en Etiek. Bloemfontein: Patmos.

Van den Berg, J-H. 1969. Medische macht en medische ethiek. Nijkerk: Callenbach.

CHAPTER 1

An introduction to healthcare ethics

Laetus O.K. Lategan and Gert J. van Zyl

AN INTRODUCTION TO HEALTHCARE ETHICS

1. CONCEPTUALISATION

The concept “ethics” finds its origin in the Greek èthos and/or êthos. These words refer to custom, practice, attitude and motive and relate to universal principles for moral human behaviour and the subsequent identification and application of norms or values derived from these principles. Essentially ethics refers to people’s moral behaviour following on a particular value system. Behaviour is informed by their deepest motivation, also known as ethos. The application of a principle is commonly referred to as norms or values.

In view of these concepts can healthcare ethics be defined as the identified principles informing the moral practices and behaviour of healthcare practitioners towards patients and the application of the values and norms in the performance and execution of healthcare. Ethics influence both healthcare practitioner and patient. In addition, ethics is also extended to healthcare management and administration, and to the habitat supporting healthcare practitioner and patient. This view corresponds with Glouberman and Mintzberg's (2001) identification of the “four worlds" in healthcare: cure, care, control and community. [See Chapter 2.2 for a description of these four worlds.]

The working definition of healthcare ethics in this book is the identification of principles and the application of values and norms informing the practice of healthcare. The scope of this definition will cover the four worlds associated with healthcare, namely cure, care, control and community.

2. ADDRESSING THE MAJOR THEMES IN HEALTHCARE ETHICS

A central theme in this book (see Introduction and Chapter 2) is that healthcare ethics cannot be limited in scope to apply only to the healthcare practitioner or only to the patient. In addition, healthcare is not restricted to the conventional settings of hospital, clinic or hospice only.

A “site” that cannot be overlooked is the practice of healthcare within a community — as part of basic healthcare or a context for research. Healthcare ethics deals with vulnerable people (healthcare practitioners, patients, communities), situations and institutions (healthcare management and administration). It is for this reason that Lategan (Chapter 2) and Vanlaere and Burggrave (Chapter 4) deal with vulnerability and ethical relationships at length. Lategan’s arguments informed the three positions taken in this book (the scope of healthcare ethics, the context for healthcare ethics and the encompassing influence of vulnerability on healthcare ethic). In addition a cosmological understanding of healthcare ethics is presented. In this presentation it is evident that ethics is always defined within a particular context and that regardless of religion and/or cultural orientation, there are universally accepted principles, values and norms that inform healthcare ethics.

It is therefore expected that (healthcare) ethics entertain the difference between right and wrong. Van Zyl and Van Zyl (Chapter 3) argue that this differentiation is not that simple, and for the health professional, may be more complex than what is sometimes envisaged. Ethics is particularly applicable to the professional practice of medicine in guiding decision making within the doctor-patient relationship, and protecting self-directedness for the patient in an essentially unequal power relationship. The maintenance of the reputation of the individual practitioner and the medical profession as a whole are important. The links with freedom, ethics, morality and professionalism are explained and some solutions are suggested. One of these solutions is the “patient charter”. Ethics is the formal expression of values and norms that a profession or business or other societal structure selects and prioritises to ensure a particular standard of moral decision making and to protect their reputation. It is ethics that transforms the subjective nature of right and wrong to an objective measure of moral behaviour.

Vanlaere and Burggraeve (Chapter 4) add a specific understanding to healthcare ethics. They approach healthcare from a quality-of-care perspective. It is evident that today, more attention is given to the quality of care than ever before. These authors link this interest to the greater emphasis that is placed on service delivery because of safety requirements and to the impact that good or poor healthcare delivery can have on healthcare systems. This raises the question as to what quality is when it comes to healthcare. For them quality demands an increase in carefulness, with its objective means and methods, and an increase in caring, with its subjective attitudes and virtues. This has a direct impact on professionalism and responsibility. As a result healthcare must be seen as a relationship and not a product. Hence an ethical framework has to inform healthcare regardless of the context and situation.

This relationship is based on an ethical obligation for healthcare practitioners to provide culturally competent, patient-centred care. MacKinnon and Comer (Chapter 5) claim that in order to do so, healthcare practitioners need to be aware of patient and family culture, values, and faith-based beliefs as they will impact end-of-life decisions, to mention but one scenario. Additionally, the culture, values and faith beliefs of the healthcare practitioner will also affect end-of-life decision making, and sometimes these two entities collide. In this chapter the authors provide some guidelines to consider in working together to make culturally sensitive end-of-life decisions. It is also evident that healthcare cannot be removed from a human rights point of view. Moore's contribution (Chapter 6) supports the notion that medical issues belong within a human rights culture. It is this culture, with its universal principles, that contributes towards the care of patients and the security of their well-being. To illustrate this point, Viljoen (Chapter 7) deals with euthanasia in a South African context. She points out that although a case can be brought before court and assisted life-end euthanasia can be granted, it still leaves the healthcare practitioner and patient in a vulnerable position. This proves the point that although an act may be legal, it does not safeguard the individual or enable the individual to be at ease with such an act.

AN INTRODUCTION TO HEALTHCARE ETHICS

In healthcare the focus is very often on the healthcare practitioner and the patient only. A neglected topic in healthcare ethics is how do we deal with communities? Lewitt, Campbell and Cross (Chapter 8) address this issue by focusing on community-based participatory research (CBPR). In CBPR community participants are actively engaged with, and influenced by, all aspects of the research process, from design to dissemination. There is a commitment to practical change in this strength-based approach, which builds trust, enhances community capacity and may lead to solutions to complex health questions that were unforeseen by the academic researchers. As healthcare research moves from working ‘on’ communities to working ‘with’ communities, a concomitant shift in the ethical orientation of healthcare practitioners is required. CBPR requires an awareness of power relationships between healthcare practitioners and the community members or service users. In CBPR the whole community should be considered the subject of research and ethical considerations should encompass respect for community as well as individual autonomy. When working with children there is a further need to work sensitively with power dynamics.

Kruger (Chapter 9) is right when he remarks that healthcare is not a new concept and several modules are available to assist the healthcare worker with the decision making process. However healthcare is a very dynamic field, causing the ethical decision making competency of healthcare workers to become more and more important but also more challenging. The healthcare worker should be aware of how changes within healthcare could influence the ethical decision making process. Healthcare workers should be aware of the multifactorial approach that is needed within the decision making process. It is recommended that an integrated approach be followed in which the healthcare worker should consider following a systematic analysis of the ethical issue at hand. The purpose of such an integrated approach is to ensure that the ethical decision making process is conducted by means of a simplified step-by-step approach. Healthcare workers must remember that they do function within a multidisciplinary team. However, the final ethical decision is essentially an individual process and the healthcare worker will take responsibility for the entire ethical decision making process no matter what approach is followed. The outcome of their ethical decisions might have a much more far-reaching effect than expected.

Another neglected theme in healthcare ethics is spirituality. This should not be confused with religion or faith. Swart (Chapter 10) unpacks this important theme and explains how spirituality can assist with the healing of a patient but also how religion and faith can open existential issues in healthcare that should be part of the holistic treatment of a patient. As healthcare practitioner, patient, healthcare management and administration and habitat may not share the same spirituality, religion and/or faith, all of those involved in healthcare should guard against making spirituality, religion or faith the condition for treatment rather than a consideration in healthcare.

AN OUTLINE OF HEALTHCARE ETHICS

Based on the discussion of what healthcare ethics is, the following outline for healthcare ethics can be presented:

Healthcare ethics is the identification of principles and the application of values and norms informing the practice of healthcare. It aims to transform a situation and to bring about a change in attitude, behaviour and practice.

Healthcare ethics cannot be limited to the patient only but covers four worlds associated with healthcare, namely cure, care, control and community.

Vulnerability includes human experiences such as ethical decision making, physical suffering, psychological disorders, economic challenges and cultural orientation. It goes without saying that every person is dependent upon other people's understanding of his/her vulnerability and therefore his/her care. In a medical context it is about caring for life, health, state of mind and general well-being.

Quality healthcare is important due to safety associated with the healthcare value chain. The core of this value chain is not healthcare as a product but healthcare as a relationship.

Healthcare ethics is informed by family, culture and religious values. Although a healthcare practitioner may not share those same values, people's values should be respected and accommodated in the practice of care and decision making. The healthcare practitioner deserves the same respect for his/her values as does the patient.

Healthcare ethics can never be removed from professional practice. Healthcare ethics should form part of healthcare education for professionals and healthcare ethics orientation for patients and their habitat.

Part of extending our understanding of healthcare is to do research within communities. This often presupposes a power relationship between those who know and those from whom the information is gathered. This situation opens the possibilities of power play and vulnerability. In dealing with communities the primary objective should remain, namely the preservation of the dignity of all involved in a project. This can be facilitated by shifting the emphasis from research on to research with.

Legality can never be removed from healthcare. It does not, however, remove ethical responsibility from healthcare. The law dictates what can be done, while ethics informs how it should be done.

AN INTRODUCTION TO HEALTHCARE ETHICS m Ethical decision making cannot be avoided. Although informed decision making is the cornerstone of ethical behaviour, proper guidance is needed to make the ‘best interest’ decision to address the ethical challenges of a particular situation.

m Spiritual needs and religious orientation should be integrated in healthcare but cannot form the basis for effective healthcare.

m Healthcare practitioners, managers and administrators should be trained, mentored and coached in dealing with healthcare ethics. Patients and their habitat should be sensitised regarding the ethical rights and responsibilities of healthcare practitioners, managers and administrators.

Glouberman, S. & Mintzberg, H. 2001. Managing the care of health and the cure of disease. Part 1: Differentiation. Health Care Management Review. Winter 56-69.

CHAPTER 2

Laetus O.K. Lategan

1. VULNERABILITY — A MULTI-PERSPECTIVE REALITY

In a case study entitled, “The Serphent was here" an account is given of an encounter in a repository of medicine which resulted in the patient's blindness. A bottle was wrongly labelled.

The case study reported by Badaracco (1998) illustrates four challenges: a patient believes that the Serphent has visited her (the Serphent, being associated with the "devil", symbolises punishment because of the wrongful personal life (personal ethics, religion) of the patient); a medical practitioner blames himself for his negligence and oversight; the hospital's superintendent realises that this may be the end of this American support programme in his country because of a mistrust that existed even before this incident; and the community's distrust has been confirmed by the misfortune.

The ethical dilemma is on truth telling because of vulnerability. If this event were to be made public it could bring an end to the work of this non-profit organisation which has been providing modern treatment for surgical disorders. The dilemmas are whether the patient should believe that the blindness was caused by the Serphent, in which case there is at least a chance to continue with this programme, or should the risk be taken and the beans be spilled, even though this might bring an end to a programme from which many people have already benefitted. Depending on the angle from which one is looking, different answers may be given (see Lategan, 2002).

In reading this case study it is evident that people (regardless of their position) are vulnerable. Vulnerability can be caused by a real life incident (an incident in a repository of medicine, for instance), inability to help (the doctor's dilemma) or mistrust from/in/of people, a programme or a situation (foreign medical assistance, for example). The case study confirms that it is not only health challenges that contribute to people's vulnerability but the way in which the treatment is experienced. In addition it is evident that neither medical staff, medical organisation nor the community in general can escape the vulnerability of ethical dilemmas in healthcare.

In looking more deeply into these ethical dilemmas, one cannot escape the fact that vulnerability is part of human existence. When people are faced by a situation (read illness) in which they are no longer in command (for example, people cannot heal themselves), this is when they realise their own vulnerability. When we observe people with their physical, emotional and human needs, then we note their vulnerability. It is therefore no surprise that ethics has as its "first" dictum not to do any harm and, by implication, to care for other people. Do no harm is coupled with do to others as they should do to you.

The implication is that vulnerability is a multi-perspective occurrence. Hence, vulnerability should be viewed from different perspectives. The intention is to promote the argument that vulnerability is not limited to patients only and that a multi-perspective view on vulnerability in healthcare ethics can contribute towards constructive guidance for everyone dealing with vulnerability in healthcare.

2; VULNERABILITY IN HEALTHCARE ETHICS - A PERSONAL ACCOUNTABILITY

As a student of medical ethics | was interested in three major issues: questions around the beginning and ending of life; questions around ethical decision making where there is an ethical conflict of interest and how societal developments impact on our understanding of illness and consequently how patients are treated — especially the vulnerable because of poverty, war and life experience.

These questions remain valid due to the ongoing ethical challenges associated with them.

To begin with, the abortion and euthanasia debates are good examples of ongoing ethical dilemmas. Legislation in South Africa moved from no abortion on demand (Act 2 of 1975 — Abortion and Sterilisation Act) to abortion on demand (Act 92 of 1996 - Choice on Termination of Pregnancy Act). Following a lengthy debate on active and passive euthanasia, the question of ending life on request has also now emerged in South Africa (in Chapter 7).

My interest in medical ethics was initially stimulated by four powerful events which influenced my research, doctoral studies and own knowledge of healthcare ethics. | will not be giving a detailed account of these events in this publication, it being sufficient to mention that the events themselves contributed to shaping my own comprehension of healthcare ethics. The mentioned events led to a shift in my own original orientation and to my quest for an in-depth understanding of healthcare ethics. To unpack these comments, the following highlights from these events can be reported:

m For some length of time | was exposed directly to vulnerable people. Their vulnerability was caused by illness, poverty, the South African border war and political unrest. | observed how life events caused people to lose trust in themselves, other people and political systems. The lack of money increased the mistrust the vulnerable people had because sometimes they could not afford basic food and livelihoods, let alone access to medicine and medical treatment. In anecdotal fashion, elderly people commented that their children, family and friends disregarded them and very often they were treated as if they no longer had the ability to make any decisions for themselves. Their lives had in effect been taken over (for geriatric references see Holtzer, 2015 and Vanlaere and Gastmans, 2010). Soldiers in the border wars and police in public unrest situations very often questioned the cause but had limited choices as the ideology of the day was informing/legitimising what they were doing. Victims, including the military and police, of global terrorism since 9/11 have opened this debate again. A relevant example is the increase in hand surgery needed as a result of explosions and fire because of combating international terrorism. As people age, there is a decline in ability and impetus. In the book of Ecclesiastics in the Bible, the Teacher describes aging and vulnerability in a poetic manner: the weaknesses of old age are described in terms of weakness in human, spiritual and sexual abilities, and life's end is compared to a broken bowl — it cannot be used for anything anymore. It was Alexander Strachan's book, "Verste Grens", that established the concept that war is not limited to a physical place, but rather that it is something that is within ourselves: he describes events that culminate in the realisation that people are vulnerable, especially in situations where events (read medical challenges) beyond their control have taken charge of their lives. These are the influences that have contributed to my desire to understand healthcare ethics and to know how to deal with vulnerable people.

The seeming contradiction between power and care presents two sides of a single theme. Power represents strength, domination, authority and dominance whilst care embodies maintenance, attention, repair and concern. It was this seeming contradiction that appealed to me and sparked the question of whether care can be provided outside the basis of power. Typical examples are the sophistication of medical technology (see for example Schuurman) and the fear of technology especially where there has been limited exposure to technology by, for instance, a patient, in a situation of communication between patient and doctor, nurse and healthcare worker; there may be little or no basis for common understanding because of the lack of exposure to technology on the part of the patient. The situation may be exacerbated in situations where gender inequality exists: not everyone is prepared to be treated by a female doctor, and an elderly person may not be comfortable taking advice from a much younger doctor. In a South African context, Phalime (2014) gives a good account of such dilemmas in her book: Post-mortem: the doctor who walked away. She notes how language inability adds to people's vulnerability. This occurs when there is limited communication between doctor and patient in situations where, for example, they cannot speak each other's language. How do you explain your challenge, or how do you respond to questions if you don't understand what is being asked? Furthermore, people fear technology if it is unfamiliar to them. If a patient lives in a remote area and has never been exposed to technology, he/ she may not be able to comprehend its benefits, and may well be afraid of it. Differences in culture, life orientation and experience can leave people in extremely vulnerable positions. Jan-Hendrik van den Berg's (1969) question as to whether we should do everything that we are able to do, lends a further dimension to the situation. The essence of this question hints at the fact that ability (read power) is not without ethical challenges. A good example may be genetic engineering (power): is it ethical to create the proverbial Frankenstein monster? Another example is the question of whether a person has the right to make decisions about his/her own death, and whether he/she may or may not decide to end his/her own life with medical assistance. Considering the contradiction between power and care sensitised me to the fact that without power (for example in the form of money, or well- trained officials) government cannot deliver basic healthcare. Poor service delivery (either through misuse of service, position and situation) can derail care and contribute towards increasing people's vulnerability. Well-known examples are hospitals that cannot optimise performance due to mismanagement or no management at all, and patients being, ill-treated, injured or even raped, for example.

Due to an emerging healthcare economy (see Remans, 2005) and the rise of managerialism in healthcare (see for example Glouberman and Mintzberg, 2001 and Creplet, 2013), a gradual shift has taken place from care for the patient to care for the organisation. Healthcare has become a commodity of significant value for medical research, pharmaceutical companies and private service providers (see Ten Have, 2011 and Creplet, 2013). It is therefore no surprise that healthcare management has become a profession in own right. From my observations, the traditional nurse's cloak has been replaced by a more modern, corporate image. At the same time, record keeping and control have been growing phenomena. As with any other major company, corporate governance and accountability have become the order of the day. Glouberman and Mintzberg (2001) have assisted tremendously by identifying four different “worlds” or “activities” in healthcare: cure, care, control and community. Although their analysis is given from a management perspective, it is most helpful in understanding the complexity of the healthcare system, its interrelatedness and interdependence and the impact of each of the ^worlds" on each other. Glouberman and Mintzberg (2011) correctly advocated a closer link between these worlds. From a healthcare perspective, the same sentiment is echoed by Creplet's (2013) suggestion that there should be more homogeneity between cure, care, control and community. In the context of this study the cure is associated with doctors, care with nurses, therapists and carers, control with the healthcare management, and community with relatives and different stakeholders in healthcare.

The case in point is simply that whether one is referring to the performing or managing of healthcare, or benefiting from healthcare, none of these should exist without the others. Linked to these different “worlds”, the claim be made that healthcare workers (as collective term for doctors, nurses, therapists and auxiliary workers), patients (regardless of the state of their health), administrators (as collective term for healthcare management) and the community (as collective term for family, friends, associates, beneficiaries if healthcare, auxiliary services) should all benefit from healthcare ethics. The shift in emphasis is also evident in what Creplet (2013) refers to as the "third revolution" in healthcare. Here technology and commercialisation impact on how healthcare is delivered. (Also see the discussion in the next paragraph on the interrelatedness of these different parties in healthcare.) This shift has also benefitted healthcare workers by acknowledging that they too, have needs. The legal and ethical debate as to whether a nurse, for example, may go on strike, is a fair indication that healthcare workers have needs too — they too are occasionally vulnerable. Vanlaere and Burggraeve (2013) correctly refer to a situation where the healthcare worker sometimes has no other option but to behave in an unethical manner because this may be his/her last resort to raise concerns about unethical practices. The conclusion that | arrived at was that healthcare ethics can no longer be limited to the needs of the patients only but must be extended beyond this. Cure, care, control and community are all in need of healthcare ethics.