3. Ethical Principles and Values in Health and Social Care

This is the third in a new series looking at different aspects of health and social care in the UK. I hope you find it interesting!

Diversity factors related to service user needs

The UK population comprises a diverse range of individuals with a variety of races, abilities, religions and cultures. For health or social care to be effective, the inequality of social experiences by different members of society must be considered at the outset if that care provision is to be fully inclusive and have an ethical and moral dimension. When we talk about diversity we mean respecting and valuing all forms of difference in individuals. People differ in all sorts of ways which may not always be obvious or visible. These differences might include race and ethnicity, culture and belief, gender and sexuality, age and social status, ability and use of health and social care services. It is recognised that some people and groups, because of a range of differences, find it more difficult to have their voice heard in mainstream society — their views, needs and perspectives may not be routinely taken into account. This can include planning services or providing truly person centred care.

At a managerial or government level, services are usually organised in response to a general identification of need, arranged around perceived characteristics of particular service groups. However, such narrow minded focus can lead to labelling. Labelling is a description applied from the outside, rather than something intrinsic to the individual themselves. Individuals with similar labels may have very different care needs and life experiences.

Ethical care provision is about addressing this inequality of social experience and ascertaining whether the response by care services condones or challenges this.

Society’s views on diversity are dynamic and progressive and accepting difference has become more the norm. Most people would argue that embracing this change is a positive thing. Evolution theory for example argues that “it is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change” (Darwin, C, 1859). However, others argue that multiculturalism is increasingly seen as a failed attempt at “social engineering.”

Society’s response to diversity may not always be a positive one and there remains discrimination, stereotyping and prejudice. Discrimination means to “differentiate” or mark out as “different”. It is a process, or more accurately a set of processes, which has the effect of disadvantaging some individuals or groups. These can have a negative effect on individuals physically, emotionally, socially or intellectually.

There is a wide range of legislation (and amendments) that cover issues of equality and discrimination including the Race Relations Act 1976, the Sex Discrimination Act 1975, the Equal Pay Act 1970, the Disability Discrimination Act 1995 and the Equality Act 2006. In health and social care contexts these laws govern the right to equitable treatment and protection from harm.

It may be argued however, that society needs to move on from tolerating and accepting difference, and instead we should “celebrate difference, because in this world it takes a lot of guts to be different” (Bornstein, 2006).

Ethical service provision and care delivery

The Oxford English Dictionary defines ethics as “moral principles that govern a person’s behaviour or the conducting of an activity.” By its very nature, care work raises all kinds of moral dilemmas on a daily basis. Knowledge of ethics can help individuals and care providers to analyse ethical dilemmas effectively.

“The ethics of care starts from the premise that as humans we are inherently relational, responsive beings and the human condition is one of connectedness or interdependence” (Gilligan, 2011). It may be argued that humans are inherently selfish. It is a view held by many moral psychologists, (most notably Thomas Hobbes). This approach dictates that even charitable works may have a selfish basis, through experiencing power over others. However, other psychologists (for example, Joseph Butler) argue that we all are all altruistic and have the capacity to show benevolence to others. Amongst the numerous ethical theories, perhaps the most well-known are deontology and utilitarianism.

Deontology (proposed by Kant et al.) is concerned with obligation or duty and the moral consequences of any actions. In essence, this approach in care provision would be mean a moral duty to act with the best intentions (being truthful for example). This approach is reason-based and being morally right, regardless of the consequences. In care provision, deontological thinking adopts a more person centred approach, which may be delivered through a long term continuous relationship.

Utilitarianism (Bentham et al.) is concerned with the greater good and for the greatest number of people. This idea focuses on the importance of the consequences of actions. Utilitarian thinkers (mainly managers and politicians) tend to value finite short term, evidence based interventions.

There may be a conflict between the utilitarian nature of overall care provision and the basic deontology of the care professional to individual service users (Garbutt and Davies, 2011). This misunderstanding may lead to waste of time and resources and poor quality services. A utilitarian approach could lead to a “postcode lottery” in which money allocated for care may not be sufficient for every geographical location due to local demographics.

Legislation associated with equitable and non-discriminatory practice

Rights are statements indicating what a person is entitled to. “To accept a set of rights is to approve a distribution of freedom and authority, and so to endorse a certain view of what may, must, and must not be done” (Stanford Encyclopedia of Philosophy, 2009). The Human Rights Act 1998 states that “some basic rights and freedoms are so important that everyone should enjoy them” (Home Office, 1998, page 2). Rights may be positive (rights of claim), for example, someone stating a care organisation had not provided appropriate support; or negative (liberties) such as the right to have your privacy respected. In 2009, legal responsibilities to protect human rights fell to the Care Quality Commission, a single, integrated regulator for England’s health and adult social care in accordance with the Health and Social Care Act, 2008.

As previously mentioned, there have been a wealth of UK laws and legislation related to equality and anti-discriminatory practice and to protect the rights of individuals. The Equality Act 2010 brought together most of the existing anti-discriminatory legislation by providing most statutory guidelines for discrimination in one legal framework. This Act makes it unlawful to discriminate against an individual on grounds of race, colour, nationality, ethnicity, gender or disability, taking into account direct and indirect discrimination, victimisation, harassment, education, employment and the provision of goods, services and facilities.

However, bringing such a large range of laws together was not without its critics. Toynbee (2009) described the “possible ramifications” as “mind-bogglingly immense. “In addition, some criticism was laid at the foot of both government and some religious groups about some of the exemptions, such as single gender short lists for Parliamentary candidates or accepting transsexual or gay men into the priesthood.

Discussion on discrimination within the care sector also needs to focus on the experiences of employees. Whilst there is a general lack of disabled individuals working within the care professions, some employers positively discriminate in favour of some disabled groups. For example, The National Autistic Society welcomes candidates with an autistic spectrum disorder.

The caring professions remain female-dominated, so the needs of male care staff need some consideration. Compared to other professions, care work is often low paid, possibly due to its being traditionally associated with female staff. It could be argued that the Equal Pay Act 1970 has done a disservice to both male and female care staff in this regard, by keeping wages low.

For effective anti-discriminatory practice and the provision of ethical care provision, care workers and providers must act in the best interests of all service users as stated in the Care Standards Act 2000. This enshrines ethical values in a legal framework and provides a set of standards for all employers and employees of care.

How care values underpin good practice

Care values underpin good practices by promoting equality and supporting diversity, being anti-discriminatory and valuing each person as an individual. Individuals who use care services may be grouped together for the convenience of arranging care delivery at the outset, but by using inclusive practice a more person- centred approach to care can be adopted whereby care is tailored to individual need. This inclusive approach empowers individuals by enabling them to make choices without fear of being discriminated against. An understanding of care values, makes care workers committed to positive action in challenging discrimination. This means being constantly mindful of the unique experiences of individuals, a willingness to learn and to change own practice when necessary and challenge myths, stereotypes and labelling. One example is to address service users “by their preferred name at all times” (Department of Health, 2000, page 16).

In a previous placement, there was a service user who was born in India and the only foreign-born resident in the home where I worked. He was also a vegetarian. I arranged with the local Hindu temple outreach charity to send him cooked meals in accordance with his dietary and cultural requirements every day. By doing so, I was respecting the gentleman’s different culture and values in accordance with my legal responsibilities and my company’s Equality and Diversity Policy.

The term “care” itself, “perpetuates the view of disabled people as separate and dependent beings, reinforcing their exclusion from mainstream society” (Carmichael and Brown, 2002, page 806). Article 8 of the Human Rights Act 1998 includes matters of self-determination. “Care workers should question the extent to which their actions promote dependency in service users” (Home Office 2000, page 18).

By taking responsibility for developing good practice, recognising gaps in service provision, then acquiring new knowledge about diversity and rights all care workers should have a more effective and productive practice, respecting the individual and being partners in care.

(n.b. This is taken from an essay that I originally wrote in 2016)

References:

Bornstein, K. (2006): Hello Cruel World: 101 Alternatives to suicide for Teens, Freaks and Other Outlaws, U.S. , Seven Stories Press

Carmichael, A. and Brown, L. (2002): The future challenge of Direct Payments’ Disability and Society, Vol 17, pages 797–808

Crown (2000): Explanatory Notes to the Care Standards Act, London, HMSO

Darwin C. (1859) : On the Origin of Species by Means of Natural Selection, or the Preservation of Favoured Races in the Struggle for Life, London, Murray

Department of Health (2000): National Minimal Standards for Domiciliary Care, London, HMSO

Fulford et al (eds) (2002): Healthcare and Human Values: An Introductory Text with Readings and Case Studies, Oxford, Blackwell

Garbutt, G. and Davies, P. (2011) : Should the practice of medicine be a deontological or utilitarian enterprise, London, Journal of Medical Ethics

GSCC (2002): Code of Practice for Social Care Workers, London, HMSO

Hoffman, D. and Rowe, J. (2006): Human Rights in the UK: An Introduction to the Human Fights Act 1998, London, Pearson,

Home Office (1998): Study Guide to the Human Rights Act, London, HMSO

Thompson, N. (2009): People Skills, Basingstoke, Macmillan

Thompson, N. (2001): Anti-Discriminatory Practice, Basingstoke, Macmillan

Thompson, N. (2003): Promoting Equality, Basingstoke, Macmillan

Toynbee, P. (2009): Harman’s law, Labour’s biggest idea for 11 years, London , The Guardian,

Zalta, E.N. et al (eds) (2009): Stanford Encyclopaedia of Philosophy, California, Stanford University Press

Website references:

Department of Health publications: www.dh.gov.uk

Ethics: www.ethicsofcare.org/carol-gilligan-21/06/2011

Skills for Care: www.skillsforcare.org.uk

Stanford University: Philosophy.stanford.edu

UK legislation: www.legislation.gov.uk